Table 1 System dynamics within the CLD: subsystems, feedback loops, mechanisms and leverage points
From: A system dynamics approach to understand Dutch adolescents’ sleep health using a causal loop diagram
Subsystem | Feedback loops | Mechanisms | Leverage points |
|---|---|---|---|
School environment: Evening homework | R1: Evening homework ↑ - presleep alertness ↑ - SOL* ↑ - sleep duration ↓ - daytime sleepiness ↑ - (see a, b, c). R2: Evening homework ↑ - (postponing) bedtime ↑ - sleep duration ↓ - daytime sleepiness ↑ - (see a, b, c). Consequences of daytime sleepiness: a. Daytime napping ↑ - evening homework ↑ b. Concentration ↓ - task efficiency ↓ - evening homework ↑ c. Impulse control ↓ - screen use ↑ - distraction ↑ /task efficiency ↓ - evening homework ↑ | Two overarching mechanisms were identified; (1) adolescents are expected to act more autonomous and demonstrate problem-solving and self-regulatory skills, such as planning their daily activities. However, they are still developing the skills to properly plan and manage their homework as well as leisure activities, causing them to often have to finish their homework in the evening. (2) Dutch regulatory organs judge the quality of a school by how well its students perform on standardized (cognitive) tests. This incentivizes schools to prioritize cognitive learning over e.g., students’ (sleep) health. This results in increased pressure on students to perform, and provide them with more schoolwork. | Event: • Reducing evening homework • Aiding students in planning their homework Structure: • Aligning school schedules with adolescents’ biorhythm (e.g., starting- and end times, breaks) • Homework coordination between teachers about when and how much homework they give • Prohibiting late-night school deadlines • No digital communication about homework from schools in the evening • Include sleep health as part of the school curriculum • Monitoring data on student sleep health (current) Goals: • Providing students with optimal cognitive, educational outcomes (not promoting adolescent (sleep) health) (current) Beliefs: • Schools are there to facilitate learning and getting good grades • Lack of teachers’/school board awareness of students sleep health (or mental health) condition • Lack of a belief or awareness that schools have a large responsibility in stimulating sleep health (sleep is something you do at home). |
School environment: School performance | B1: Poor school performance ↑ - performance pressure through self-inducing, peers, school and parents ↑ - homework supervision/tutoring ↑ - poor school performance ↓ R3 Poor school performance ↑ - performance pressure adolescent themselves, peers, from school, parents ↑ - evening homework ↑ - … a. …presleep alertness ↑ - SOL ↑ - … b. …bedtime ↑ -… …sleep duration ↓ - daytime sleepiness ↑ - concentration ↓ - poor school performances & progress ↑ | ||
School environment: School starting times | No feedback loops identified | School start times were a stand-alone factor in the CLD, yet still of significant importance. Synchronizing them with adolescents’ circadian rhythm benefits their (sleep) health, all-round daytime functioning and consequently school performances. | |
Mental wellbeing: Performance pressure | R4: Performance pressure, through self-inducing, peers, school, and/or parents ↑ - presleep worrying ↑ - presleep alertness ↑ - SOL ↑/ wake up time ↓ - sleep duration ↓ - daytime sleepiness ↑ - concentration ↓ - poor school, sports and job performances ↑ - performance pressure ↑ R5: Performance pressure ↑ - presleep worrying ↑ - presleep alertness ↑ - screen use ↑ - exposure arousing/negative content ↑ - feeling of striving for perfection ↑ - performance pressure ↑ | Today’s adolescent experiences significant peer pressure, continuously reinforced by today’s ever-present social media platforms and influencers, to live ‘the perfect life’, i.e., be ‘successful’, have an active social life, a good reputation and always-perfect, beautiful appearance. Adolescents indicated that as a result they mainly place much pressure on themselves, because they want to comply with this ‘perfect picture’. Pressure from school and parents also appeared to contribute to the feeling of pressure to perform well at school as students are assessed in a summative way and have to choose an educational level at an early stage of their high-school career**. Parents themselves feel the pressure to track their child’s progress and achievements via schools’ digital tracking systems/apps, and then ‘stimulate’ them to perform well. The ideology of our current society is also focused on the individual and performance. Parents in turn also perceive this norm and may reflect this on their children. | Event: • Providing adolescents with knowledge, awareness, skills and tools to cope with stress & presleep worrying (e.g., relaxing sleep hygiene practices) • Providing more opportunities to talk about mental health (e.g., at school) • No digital communication (e.g., about homework, grades, schedule changes) from schools in the evening • More attention for (cyber)bullying • Providing adolescents with awareness and skills to cope with people portraying a ‘perfect life’ online. Structure: • Schools limit their digital communication structures with students and parents • Perceived pressure from parents: restricting parental digital access to school performances • Schools do not focus solely on summative assessment • Requirements/standards for further education are not based on summative assessment only • Mental health is included in the school curriculum (current) Goals: • Adolescents: complying with the social norm and getting recognition from peers • Parents: ensuring the best possible future for their child • Schools: maximizing cognitive learning • Society: being successful (i.e., dependent one’s education, carrier, income, housing, appearance and social circle) (current) Beliefs: • Performance culture (i.e., you are responsible for your own life satisfaction and success) • Norm to not speak about mental wellbeing and seeking professional help |
Mental wellbeing: Presleep worrying | R6: Presleep worrying ↑ - presleep alertness ↑ - SOL ↑/wake up time ↓ - sleep duration ↓ - emotion regulation ↓ - presleep worrying ↑ | ||
Mental wellbeing: Screen use & social media | R7: Presleep worrying ↑ - presleep alertness ↑ - screen use ↑ - exposure arousing/negative content ↑ - (see a, b, c, d) Consequences of exposure arousing/negative content: a. Presleep worrying ↑ b. Cyberbullying ↑ - presleep worrying ↑ c. Uncertainty appearance ↑ - presleep worrying ↑ d. Feeling of striving for perfection ↑ - performance pressure ↑ R8: Presleep worrying ↑ - SOL ↑ - presleep worrying ↑ B2: Presleep worrying ↑ - presleep alertness ↑ - screen use ↑ - social support/emotion suppressing ↑ - presleep worrying ↓ | Adolescents often use their phone late in the evening and in bed as a means to calm down and ‘switch off’ from all that goes on in their day and the often stressful thoughts that come with it causing. It also enables them to talk to friends about their thoughts and problems. However, conversely, such conversations and social media content also reinforce their worries, feelings of FOMO and keep them attached to their phone, often until deep in the night. Once they notice they can’t get enough sleep that night it even increases presleep worrying. | |
Digital environment: Postponing bed- and sleep timing | R9: Screen use ↑ - exposure appealing design social media/game platforms ↑ - screen use ↑ (thereby postponing bed timing/sleep timing). R10: Screen use ↑ - exposure appealing design social media/gaming platforms ↑ - positive attitude of teens about sleep health ↓ - intention of teens to go to bed/sleep/stop screen use ↓ - screen use ↑ B3: Screen use ↑ - exposure appealing design of social media/gaming platforms ↑ - FOMO ↑ - presleep worrying ↑ - presleep alertness ↑ - SOL ↑ - sleep duration ↓ - tired appearance of teenagers ↑ - uncertainty appearance ↑ - intention of teens to go to bed/sleep/stop screen use ↑ - screen use ↓ | The prevailing social norm among adolescents that keeps them up at night is that they are expected to be available 24/7, and to always be online. These norms reinforce screen use but also create late bedtime norms among peers. For adolescents is screen use and social media of extra importance as it is a way for adolescents to explore their identity and express themselves. It is thereby an extension of their personal identity. Social media platforms tap into this need of adolescents to express themselves, explore their identity and search for peer confirmation. By using digital data they create a personalized, cultivated space which is appealing. Their goals is to maximize profits (e.g., via advertisements) and keep you online constantly using captivating mechanisms (e.g., notifications, social media challenges). | Event: • Providing adolescents with knowledge, awareness, positive attitude, self-efficacy and skills (e.g., to cope with FOMO and cultivating mechanisms) Structure: • Adolescents: Screen use (e.g., social media and gaming) are important communication ‘structures’ for teenagers. But also a way to explore their identity and express themselves • School: Screen use at school for schoolwork contributes to efficiency • (social) media companies: the compulsive ‘structures’ or environments of media platforms by using personal digital data (current) Goals: • Adolescents: conform with their peers and adhere to the social norm • (social) media companies: • Maximize profits by increasing social media and screen use. • Improve and maximize efficiency and convenience of daily life activities as the use of technology can simplify time-consuming tasks (current) Beliefs: • Adolescent screen use norm, i.e., it is normalized to be online in the evening, it is expected that you are 24/7 available and that social media is an extension of our personal identity (i.e., many reactions, followers and likes is comparable to popularity and being liked) • Technological innovations are necessary to function in daily life (e.g., school work, entertainment, communication, payments, setting alarm clocks) |
Digital environment: Fear of Missing Out & peers | R11: Screen use ↑ - exposure appealing design social media/game platforms ↑ - FOMO ↑ - presleep worrying ↑ - presleep alertness ↑ - screen use ↑ R12: Screen use by peers ↑ - amount of content on social media/gaming platforms ↑ - receiving notifications ↑ - FOMO ↑ - presleep worrying ↑ - presleep alertness ↑ - screen use ↑ - screen use by peers ↑ | ||
Digital environment: Peer norms | R13: Screen use by peers ↑ - late bedtime norms peers ↑ - screen use ↑ - screen use by peers | ||
Family & Home environment: Parenting practices | R14: Appropriate parenting sleep/screen hygiene rules/practices ↓ - resistance of teenagers ↑ - negative parental experiences parenting sleep/screen practices ↑ - parental self-efficacy ↓ - parental intention to improve and monitor adolescent sleep health ↓ - appropriate parenting sleep/screen hygiene rules/practices ↓ (later bedtiming/sleep timing/more screen use) B4: Parental self- efficacy ↓ - need of social support (e.g., talking to other parents, help from organisations) ↑ - obtaining accessible information/guidance ↑ - parental knowledge of sleep health ↑ - subjective norm among parents on late adolescent bedtime ↓ - parental self-efficacy ↑ | Parents often struggled with their changing role towards their adolescent. Although specific situations may vary per type of parenting style, most parents struggle with their role from manager to coach to mentor through adolescence, especially in context of their child’s sleep health. | Event: • Aiding parents with setting, monitoring and enforce appropriate parenting practices (e.g., bedtime, sleep time and screen use) • Aiding parents to be a good role model (e.g., parental evening screen use, bedtime) • Providing parents with knowledge, positive attitude, awareness, self-efficacy and skills to improve sleep health of their children Structure: • Busy day to day lives (less priority for parenting practices and less insight into adolescent behavior) • Creating accessible ways for parents to obtain information, guidance and exchanging experiences with other parents • Improving municipal access to financial resources for low socio-economic status families to enable them to create a healthy sleep environment (current) Goals: • Parents: their teenagers should grow up happily and in good physical and mental state. • Parents: do good as a parent and facilitate the best possible future for their child. • Parents: have a good relationship with their child • Parents: having the highest educational level possible for their child (current) Beliefs: • Parental norm around sleep and screen parenting • Parental belief that higher educational qualifications of their child enables financial independence and betters their chances in life. • Seeking parental help is perceived as failing as a parent. • Adolescents at this age range should take their own responsibility or • Adolescents at this age range can’t take all responsibilities and still need a guiding role from their parents |
Family & Home environment: Household factors | No feedback loops identified | Certain household characteristics significantly influence adolescent sleep health directly (e.g., unsafe neighborhood, housing quality) and indirectly (e.g., financial stress decreasing the priority for parents to set rules). | |
Health behaviors & Leisure activities: Sports, hobbies & jobs Food, drink and medicine consumption | R15: Daytime physical activity, sports, side-jobs & hobbies ↑ - natural daylight exposure ↑ - SOL ↓ - sleep duration ↓ - daytime sleepiness ↑ - daytime sports, hobbies & jobs ↑ B5: Daytime physical activity, sports, side-jobs & hobbies ↑ - evening homework ↑ - presleep alertness ↑ & postponing bedtime ↑ - sleep duration ↓ - daytime sleepiness ↑ - daytime sports ↓ R16: Intake of fatty foods & sugary/caffeinated drinks ↑ - presleep alertness ↑ - SOL ↑ - sleep duration ↓ - daytime sleepiness ↑ - intake of fatty foods & sugary/caffeinated drinks ↑ B6: Concentration ↓ - intake of fatty foods & sugary/caffeinated drinks ↑ - concentration ↑ B7: SOL ↑ - intake of sleep aids adolescents ↑ - SOL ↓ | When adolescents have an inadequate sleep health they behave more unhealthy: they eat more fast fatty and sugary foods and they move less during the day because they feel tired. In addition, hormone regulation of ghrelin and leptin become unstable when sleep deprived. Ghrelin levels rises and leptin levels decreases which stimulates eating. | Event: • Decreasing adolescents’ consumption of fatty foods & sugary/caffeinated drinks in the evening • Stimulating daytime physical activity • Discouraging evening sports, hobbies & side-jobs • Aiding adolescents with planning homework, side-jobs, sports, hobbies and other leisure activities Structure: • Evening working hours of side-jobs and sports activities Goals: - (current) Beliefs: • Norm intake sleep aids |
Personal system Psychosocial factors | No feedback loops identified | Certain personal factors (e.g., knowledge, attitudes, self-efficacy, skills) are important preconditions for proper sleep health. As with many other health-related behaviors, these factors are often insufficient, yet necessary elements for behavior change. Having the intention to perform healthy sleep-related behavior is not enough as adolescents perceive many barriers (i.e., competitive behaviors such as evening homework, sports/hobbies, screen use). One of the effects of these competitive behaviors is that adolescents often think sleep is a waste of their time. | Event: • Providing adolescents with knowledge, awareness, positive attitude, self-efficacy and skills to improve their sleep health Structure: - Goals: - (current) Beliefs: • Adolescents: norm about sleep • Sleep is a waste of my time • Sleep is not important • Going to bed late is cool • Peers also go to bed late |