Adolescence, which is typically defined as the second decade of life, ages 10–19 (Singh et al., 2019), is associated with many biological, psychological, and social changes (Steinberg, 2005). This developmental window is also associated with heightened sensitivity to stress (Romeo, 2010), or the subjective physiological, cognitive, emotional, and/or behavioral experience of an individual when their demands exceed their coping capacities (Lazarus, 1966; Cohen et al., 1995). Since the COVID-19 pandemic, adolescent stress levels have increased, with nearly 70% of adolescents reporting higher levels of stress (Mayne et al., 2021), with rates generally higher for female adolescents (Østerås et al., 2016). These effects have had consequences on multiple psychosocial domains, including school functioning, peer functioning, and pain (Kaczynski et al., 2021). Although some stress can be beneficial for development, extensive longitudinal research indicates that high levels of stress in youth can increase risk for mental health disorders (Grant et al., 2004; Lindholdt et al., 2022) and be associated with numerous negative psychosocial outcomes, including challenges with school functioning, peer relationships, and pain (Østerås et al., 2016; Gazelle and Rubin, 2019).

Adolescents also undergo normative changes in sleep, which, similar to stress, have been impacted by the pandemic. Sleep relates to many health and psychosocial domains in adolescence, such as depression (Lovato and Gradisar, 2014), risk-taking (Short and Weber, 2018) and even suicidal behavior (Baldini et al., 2024). Adolescent sleep is also often quite variable (Dong et al., 2019). Although some adolescents reported less daytime sleepiness and longer sleep duration during the pandemic (Becker et al., 2021), difficulties initiating and maintaining sleep increased significantly for adolescents, and meta-analytic work points to an overall negative impact on sleep from pre- to post-pandemic onset (Corrêa et al., 2024). These pandemic-related changes may be associated with decreases in structure and demands alongside increases in general distress, sadness, and loneliness (Becker et al., 2021). Underlying many adolescent sleep difficulties are normative developmental changes including alterations to the sleep/wake homeostatic process and the circadian timing system (Carskadon, 2011). Although the American Academy of Sleep Medicine recommends that adolescents sleep between 8 and 10 h each night (Paruthi et al., 2016), most youth report lower sleep duration, poor sleep satisfaction, and poor sleep quality (Dong et al., 2019). Differences related to gender also suggest that females (Marczyk Organek et al., 2015) and nonbinary adolescents (Harry-Hernandez et al., 2020) get less sleep than male adolescents. The mechanisms by which these gender differences emerge are hypothesized to be related to pubertal timing and onset of menses (Johnson et al., 2006; Knutson, 2005; Holm et al., 2009).

Sleep may mediate associations between stressful psychosocial factors in adolescence (Peltz et al., 2019). Poor sleep quality is cross-sectionally associated with chronic stress, and increased levels of stress contribute to worse sleep quality (Amaral et al., 2018). Sleep disturbances are also closely related to school-related difficulties as poor sleep quality can lead to increased levels of daytime sleepiness, often associated with worse school performance across genders, both cross-sectionally and longitudinally (Dewald et al., 2010; Fredriksen et al., 2004). Insufficient sleep is also associated with poor academic achievement and weakened emotional-behavior regulation (Schmidt and Van der Linden, 2015). Likely related to sleep-related difficulties with emotional-behavioral regulation, ongoing sleep disturbance is also associated with worse interpersonal and social functioning (McGlinchey et al., 2017). Further, sleep is also bidirectionally associated with pain. In adolescents with chronic pain conditions, which typically affect females more than males, poor sleep is associated with increased next-day pain, and increases in pain impact quality of sleep (Bromberg et al., 2012). Less studied, however, is the interplay between sleep and pain intensity in adolescents without diagnosed chronic pain conditions. Investigating sleep as a potential mediator between stressful psychosocial factors is critical as its transdiagnostic nature (Harvey et al., 2011; Phillips et al., 2024) and demonstrated modifiability (Harvey et al., 2018) position it as a promising mechanism of and target for adolescent psychosocial intervention.

The goal of the current cross-sectional study was to take a biopsychosocial approach to examining the potential mediating effects of sleep quality on associations between stress and school functioning, peer functioning, and pain in a community sample of US adolescents, following the emergency phase of the pandemic. Biologically, our proposed model includes factors relevant to physical health, such as pain. Psychobiologically, our model incorporates sleep and stress, both of which can impact psychological functioning as well as physical well-being (Morales-Muñoz and Gregory, 2023). Finally, our model examines peer functioning and school functioning, which are critical psychosocial elements of adolescent well-being (Becker et al., 2015). We hypothesized that sleep quality would explain, to some extent, the associations between stress and decreased school functioning, decreased peer functioning, and increased pain. In addition, we investigated binary gender differences for the potential explanatory association of sleep quality with these psychosocial constructs.

The total sample consisted of 236 adolescents (mean age = 15.66 years, SD = 1.07); 94.1% (N = 225) with complete data. Overall, there was only 0.38% of missing data. Results of the Little’s tests indicated that all missing data was missing completely at random, therefore multiple imputation was conducted. See Table 1 for demographic information.

The current study investigated the potential mediating effect of sleep quality on associations between stress and school functioning, peer functioning, and pain in a community sample of adolescents. Consistent with our hypothesis, sleep quality significantly accounted for the association between stress and school functioning, and to a lesser extent, between stress and pain. Sleep quality did not significantly account for the association between stress and peer functioning. We discuss these results further and suggest their potential implications for future research and clinical practice.

First, our results indicated that sleep quality significantly accounted for the association between stress and school functioning, explaining 82% of this association across male, female, and non-binary adolescents. Our analyses by binary gender further showed that the indirect effect of sleep quality accounted for approximately 91% of the effect of stress on school functioning for adolescent girls and 86% of the effect for adolescent boys. This finding aligns with prior research showing that insufficient sleep and sleepiness are associated with poorer academic functioning, likely related to the cognitive impact on sleep disturbance for adolescents’ learning, memory, and concentration (Dewald et al., 2010).

Second, our findings revealed that sleep quality significantly accounted for the association between stress and pain, particularly for adolescent females. This is consistent with prior work in the adolescent pain literature highlighting the negative effects of poor sleep on pain, suggesting that associations between sleep and pain exist for youth, even in the absence of diagnosed pain conditions (Clementi et al., 2020). Contrary to our hypothesis, sleep quality did not link the association between stress and peer functioning in the current sample. Although prior research has indicated negative associations between sleep and interpersonal functioning in adolescents, the current study assessed specifically adolescent social functioning in the context of peers (Sarchiapone et al., 2014). The effect of sleep on interpersonal functioning could possibly be specific to relationships with family and adults, rather than peers. Many studies identifying a link between sleep and social functioning have not reported only on peer functioning, rather more general interpersonal relationships (McGlinchey et al., 2017). Other studies have shown significant associations between sleep disturbances and peer-related problems in adolescence, such as loneliness and victimization or bullying (Kubiszewski et al., 2014). Future research would benefit from clarifying associations between sleep and specific domains of interpersonal functioning.

Our analyses related to gender indicated no significant differences across models for male versus female adolescents. Due to our small sample size, however, we were unable to draw claims about sleep quality for non-binary adolescents. We therefore suggest that future work investigate sleep experiences of gender minority youth as burgeoning evidence indicates high rates of sleep difficulties in both non-binary adults and adolescents (Harry-Hernandez et al., 2020). Better understanding sleep experiences of gender minority youth is critical for bolstering our understanding of adolescent sleep disparities (Marczyk Organek et al., 2015).

Investigating adolescent sleep quality as a mechanism holds promise as a modifiable transdiagnostic pathway toward adolescent health. Indeed, studies show that interventions can improve adolescent sleep through school-based, transdiagnostic, and disorder-specific treatments (Harvey et al., 2018; Harvey, 2016). Better sleep is associated with positive outcomes, including decreased risk in emotional, cognitive, and social domains (Dong et al., 2019). It is also associated with fewer physical symptoms and lower rates of obesity, mood, and anxiety disorders (Dong et al., 2019). Moreover, sleep is associated positively with memory, language, executive function, overall cognitive development, and physical growth in youth (Tham et al., 2017). Findings from the current study suggest that interventions targeted to improve sleep quality in adolescents may also have downstream effects on their school functioning and pain. Notably, as compared to training adolescents in coping skills for stress-reduction that are often difficult to implement in the moment, sleep-related intervention, such as modifying sleep hygiene behaviors, may represent a relatively accessible approach to psychosocial improvement (Ten Brink et al., 2021). From a societal perspective, our findings also highlight the importance of prioritizing adolescent sleep health in policy decisions. For example, longitudinal work has shown that providing adolescents with later school start times increases their sleep duration (Meltzer et al., 2021a).

We suggest that future research build upon the limitations of the current study. First, the current study is cross-sectional, thus limiting our ability to make claims of temporal or causal nature amongst our variables (Maxwell and Cole, 2007). To that end, we suggest future studies examine longitudinally the potential mediating role of sleep quality on associations between stress and psychosocial outcomes over time. Longitudinal investigations can also better parse the often bidirectional association between poor sleep quality and later stress (Ten Brink et al., 2021). Second, our sample consisted of an overwhelming majority of adolescents with binary gender identities. Larger, more gender-diverse samples will be necessary to investigate the sleep experience for non-binary adolescents. Third, our study relied on self-report measures, which are subject to reporter and recall bias (Macchiarola et al., 2022). Specifically, we recommend that future work assessing the mechanistic role of sleep employ objective measures of sleep (e.g., consumer-grade wearable devices, actigraphy watches). Relatedly, we also suggest future research studies incorporate a more comprehensive assessment of the multidimensional constructs of adolescent sleep health, such as regularity, timing, and efficiency of sleep (Meltzer et al., 2021b).

In conclusion, the current study tested the cross-sectional mechanistic role of sleep quality on associations between stress and social functioning, peer functioning, and pain in a community sample of adolescents. Our findings highlight how sleep quality may explain a significant proportion of the effect of stress on school functioning, and a smaller portion of the effect of stress on pain. No studies to the authors’ knowledge have examined these particular associations in adolescents since lockdown. Future research and clinical practice should continue to investigate sleep as a modifiable mechanism underlying adolescent psychosocial outcomes with the potential to buffer the effects of stress.