Assessment and Treatment of Delayed Sleep Phase Disorder in Adolescents

Circadian preference and mental health outcomes in youth: A systematic review and meta-analysis

Youth is a vulnerable developmental period associated with an increased preference for eveningness and risk for developing psychopathology. Growing evidence suggests a link between eveningness and poorer mental health outcomes, but the findings in the current literature are inconsistent, and a comprehensive synthesis of evidence in this area remains lacking. This meta-analysis aimed to 1) synthesise the existing evidence on the association between circadian preference and mental health outcomes in youths and 2) explore potential sleep-related factors that may moderate the relationship between circadian preference and mental health outcomes. A systematic search of five electronic databases resulted in 81 observational studies included in the review. Eveningness was found to be significantly associated with general mental health (r = 0.20), mood-related disturbances (r = 0.17), and anxiety problems (r = 0.13). The qualitative review also identified that eveningness was associated with greater risks for psychotic symptoms and maladaptive eating behaviours. These findings highlighted the need to consider circadian preference in the clinical management of youth mental health problems. Further research is needed to examine the efficacy of a circadian-focused intervention in the context of youth mental health.

Cognitive Behavioral Therapy for Insomnia in School-Aged Children and Adolescents

One of the most prevalent sleep disorders in children and adolescents is "insomnia," which can be briefly described as problems with initiating and/or maintaining sleep with associated daytime consequences. These are typical insomnia symptoms, and when experienced for long enough and when they interfere with an important area of the young person's life (eg, schooling), then a diagnosis of an insomnia disorder may be warranted. The authors strongly urge the scientific community to conduct further controlled trials, including dismantling trials that evaluate the relative effectiveness of individual cognitive behavioral therapy for insomnia components.

Sleep’s role in the development and resolution of adolescent depression

Two adolescent mental health fields — sleep and depression — have advanced largely in parallel until about four years ago. Although sleep problems have been thought to be a symptom of adolescent depression, emerging evidence suggests that sleep difficulties arise before depression does. In this Review, we describe how the combination of adolescent sleep biology and psychology uniquely predispose adolescents to develop depression. We describe multiple pathways and contributors, including a delayed circadian rhythm, restricted sleep duration and greater opportunity for repetitive negative thinking while waiting for sleep. We match each contributor with evidence-based sleep interventions, including bright light therapy, exogenous melatonin and cognitive-behaviour therapy techniques. Such treatments improve sleep and alleviate depression symptoms, highlighting the utility of sleep treatment for comorbid disorders experienced by adolescents.

Sleep problems are both a symptom and precursor of adolescent depression. In this Review, Gradisar et al. describe how the combination of adolescent sleep biology and psychology predisposes adolescents to develop depression, and describe interventions that improve sleep and depression symptoms in this population.

Sleep and circadian instability in delayed sleep-wake phase disorder

STUDY OBJECTIVES

In patients with delayed sleep-wake phase disorder (DSWPD), the circadian clock may be more easily affected by light at night. This creates a potential vulnerability, whereby individuals with irregular schedules may have less stable circadian rhythms. We investigated the stability of circadian timing and regularity of sleep in patients with DSWPD and healthy controls.

METHODS

Participants completed 2 dim-light melatonin onset (DLMO) assessments approximately 2 weeks apart while keeping their habitual sleep/wake schedule. After the second DLMO assessment, light sensitivity was assessed using the phase-resetting response to a 6.5-hour 150-lux stimulus. The change in DLMO timing (DLMO instability) was assessed and related to light sensitivity and the sleep regularity index.

RESULTS

Relative to healthy controls, patients with DSWPD had later sleep rhythm timing relative to clock time, earlier sleep rhythm timing relative to DLMO, lower sleep regularity index, and greater DLMO instability. Greater DLMO instability was associated with increased light sensitivity across all participants, but not within groups.

CONCLUSIONS

We find that circadian timing is less stable and sleep is less regular in patients with DSWPD, which could contribute to etiology of the disorder. Measures of light sensitivity may be informative in generating DSWPD treatment plans.

Design of multi-particulate "Dome matrix" with sustained-release melatonin and delayed-release caffeine for jet lag treatment

Multi-particulate Dome matrix with sustained-release melatonin and delayed-release caffeine was designed to restore jet lag sleep-wake cycle. The polymeric pellets were produced using extrusion-spheronization technique and fluid-bed coated when applicable. The compact and Dome module were produced by compressing pellets with cushioning agent. Dome matrix was assembly of modules with pre-determined compact formulation and drug release characteristics. The physicochemical and in vivo pharmacokinetics of delivery systems were examined. Melatonin loaded alginate/chitosan-less matrix exhibited full drug release within 8 h gastrointestinal transit with low viscosity hydroxypropymethylcellulose as cushioning agent. The cushioning agent reduced burst drug release and omission of alginate-chitosan enabled full drug release. Delayed-release alginate-chitosan caffeine matrix was not attainable through polymer coating due to premature coat detachment. Admixing of cushioning agent high viscosity hydroxypropylmethylcellulose and high viscosity ethylcellulose (9:1 wt ratio) with coat-free caffeine loaded particulates introduced delayed-release response via hydroxypropylmethylcellulose swelled in early dissolution phase and ethylcellulose sustained matrix hydrophobicity at prolonged phase. The caffeine was released substantially in colonic fluid in response to matrix polymers being degraded by rat colonic content. Dome matrix with dual drug release kinetics and modulated pharmacokinetics is produced to introduce melatonin-induced sleep phase then caffeine-stimulated wake phase.

Chrono-Nutrition and Diet Quality in Adolescents with Delayed Sleep-Wake Phase Disorder

Background: Delayed sleep-wake phase disorder (DSPD), characterized by delayed sleep-onset and problems with awakening in the morning, is mostly prevalent in adolescents. Several studies have suggested chrono-nutrition could present a possible modifiable risk factor for DSPD. Objective: To describe differences in chrono-nutrition and diet quality in adolescents with DSPD compared to age-related controls. Methods: Chrono-nutrition and diet quality of 46 adolescents with DSPD, aged 13–20 years, and 43 controls were assessed via questionnaires. Diet quality included the Dutch Healthy Diet index (DHD-index) and Eating Choices Index (ECI). Results were analysed using logistic regression and Spearman’s partial correlation. Results: Compared with controls, DSPD patients consumed their first food of the day significantly later on weekdays (+32 ± 12 min, p = 0.010) and weekends (+25 ± 8 min, p = 0.005). They consumed their dinner more regularly (80.4% vs. 48.8%, p = 0.002) and consumed morning-snacks less frequently (3.0 ± 2.1 days vs. 4.2 ± 1.7 days, p = 0.006). No differences in clock times of breakfast, lunch, or dinner were found. Moreover, no significant differences in overall diet quality were observed. Conclusion: This descriptive study showed chrono-nutritional differences between adolescents with and without DPSD. Further studies are needed to explore features of chrono-nutrition as a possible treatment of DPSD.

Altering Adolescents' Pre-Bedtime Phone Use to Achieve Better Sleep Health

Mobile phone use is often blamed for adolescent sleeping difficulties in the popular and scientific literature, with correlations observed between adolescents' mobile phone use and their bedtime. We aimed to obtain experimental evidence to support these causal claims. A within-subjects experiment (baseline, intervention) was conducted in adolescents' homes, to determine the effect of restricting adolescents' pre-bed mobile phone use on school night sleep habits. Following a baseline week, adolescents were given individualized phone stop times, 1 hour before bed for one school week. An online sleep diary was used to monitor bedtime, lights out time, sleep latency and total sleep. Sixty three adolescents (age range 14-18, M = 16.3, SD = 0.93yrs; 17%male) provided data. During one week of phone restriction, adolescents stopped using their phones earlier (80 min, p < .001), turned their lights off earlier (17 min, p = .01), and slept longer (21 min, p = .01). Participant recruitment was low (26%), indicating many adolescents lack motivation to negotiate changes to their evening phone use. Overall, there are potential benefits of restricted mobile phone use during the pre-sleep period, yet, future research is needed to identify non-technological interventions to increase adherence to phone restriction (e.g., motivational interviewing) or otherwise decrease pre-sleep arousal (e.g., cognitive strategies).

Cognitive Behavioral Therapy for Insomnia (CBT-i) in School-Aged Children and Adolescents

Insomnia is one of the most prevalent sleep disorders in school-aged children and adolescents. Although cognitive behavioral therapy for insomnia (CBT-i) is the first-line treatment for adults, and existing studies show promising effects also for children and adolescents, the number of randomized controlled trials in younger age groups is rather small. CBT-i techniques for school-aged children and adolescents include bedtime shifts (including sleep restriction), stimulus control, thought challenging, psychoeducation, and relaxation techniques. The integration of parents, especially in school-aged children with insomnia, is highly recommended. More research is needed to investigate specific characteristics and models of child and adolescent insomnia.

Youth Screen Media Habits and Sleep: Sleep-Friendly Screen Behavior Recommendations for Clinicians, Educators, and Parents

With the widespread use of portable electronic devices and the normalization of screen media devices in the bedroom, insufficient sleep has become commonplace. In a recent literature review, 90% of included studies found an association between screen media use and delayed bedtime and/or decreased total sleep time. This pervasive phenomenon of pediatric sleep loss has widespread implications. There is a need for basic, translational, and clinical research examining the effects of screen media on sleep loss and health consequences in children and adolescents to educate and motivate clinicians, teachers, parents and youth themselves to foster healthy sleep habits.

A randomised controlled trial of bright light therapy and morning activity for adolescents and young adults with Delayed Sleep-Wake Phase Disorder

A randomised controlled trial evaluated bright light therapy and morning activity for the treatment of Delayed Sleep-Wake Phase Disorder (DSWPD) in young people. 60 adolescents and young adults (range = 13-24 years, mean = 15.9 ± 2.2 y, 63% f) diagnosed with DSWPD were randomised to receive three weeks of post-awakening Green Bright Light Therapy (∼507 nm) and Sedentary Activity (sitting, watching TV), Green Bright Light Therapy and Morning Activity (standing, playing motion-sensing videogame), Red Light Therapy (∼643 nm) and Sedentary Activity or Red Light Therapy and Morning Activity. Sleep (ie sleep onset time, wake up time, sleep onset latency, total sleep time) and daytime functioning (ie morning alertness, daytime sleepiness, fatigue, functional impairment) were measured pre-treatment, post-treatment and at one and three month follow-up. Contrary to predictions, there were no significant differences in outcomes between treatment groups; and interaction effects between treatment group and time for all outcome variables were not statistically significant. However, adolescents and young adults in morning activity conditions did not meaningfully increase their objective activity (ie movement frequency). Overall, adolescents reported significantly improved sleep timing (d = 0.30-0.46), sleep onset latency (d = 0.32) and daytime functioning (d = 0.45-0.87) post-treatment. Improvements in sleep timing (d = 0.53-0.61), sleep onset latency (d = 0.57), total sleep time (d = 0.51), and daytime functioning (d = 0.52-1.02) were maintained, or improved upon, at the three month follow-up. However, relapse of symptomology was common and 38% of adolescents and young adults requested further treatment in addition to the three weeks of light therapy. Although there is convincing evidence for the short-term efficacy of chronobiological treatments for DSWPD, long-term treatment outcomes can be improved. To address this gap in our current knowledge, avenues for future research are discussed.

CLINICAL TRIAL

Australian & New Zealand Clinical Trials Registry, https://www.anzctr.org.au, ACTRN12614000308695.

Adolescent Executive Dysfunction in Daily Life: Relationships to Risks, Brain Structure and Substance Use

During adolescence, problems reflecting cognitive, behavioral and affective dysregulation, such as inattention and emotional dyscontrol, have been observed to be associated with substance use disorder (SUD) risks and outcomes. Prior studies have typically been with small samples, and have typically not included comprehensive measurement of executive dysfunction domains. The relationships of executive dysfunction in daily life with performance based testing of cognitive skills and structural brain characteristics, thought to be the basis for executive functioning, have not been definitively determined. The aims of this study were to determine the relationships between executive dysfunction in daily life, measured by the Behavior Rating Inventory of Executive Function (BRIEF), cognitive skills and structural brain characteristics, and SUD risks, including a global SUD risk indicator, sleep quality, and risky alcohol and cannabis use. In addition to bivariate relationships, multivariate models were tested. The subjects (n = 817; ages 12 through 21) were participants in the National Consortium on Alcohol and Neurodevelopment in Adolescence (NCANDA) study. The results indicated that executive dysfunction was significantly related to SUD risks, poor sleep quality, risky alcohol use and cannabis use, and was not significantly related to cognitive skills or structural brain characteristics. In multivariate models, the relationship between poor sleep quality and risky substance use was mediated by executive dysfunction. While these cross-sectional relationships need to be further examined in longitudinal analyses, the results suggest that poor sleep quality and executive dysfunction may be viable preventive intervention targets to reduce adolescent substance use.

Eveningness and Later Sleep Timing Are Associated with Greater Risk for Alcohol and Marijuana Use in Adolescence: Initial Findings from the National Consortium on Alcohol and Neurodevelopment in Adolescence Study

BACKGROUND

Abundant cross-sectional evidence links eveningness (a preference for later sleep-wake timing) and increased alcohol and drug use among adolescents and young adults. However, longitudinal studies are needed to examine whether eveningness is a risk factor for subsequent alcohol and drug use, particularly during adolescence, which is marked by parallel peaks in eveningness and risk for the onset of alcohol use disorders. This study examined whether eveningness and other sleep characteristics were associated with concurrent or subsequent substance involvement in a longitudinal study of adolescents.

METHODS

Participants were 729 adolescents (368 females; age 12 to 21 years) in the National Consortium on Alcohol and Neurodevelopment in Adolescence study. Associations between the sleep variables (circadian preference, sleep quality, daytime sleepiness, sleep timing, and sleep duration) and 3 categorical substance variables (at-risk alcohol use, alcohol bingeing, and past-year marijuana use [y/n]) were examined using ordinal and logistic regression with baseline age, sex, race, ethnicity, socioeconomic status, and psychiatric problems as covariates.

RESULTS

At baseline, greater eveningness was associated with greater at-risk alcohol use, greater bingeing, and past-year use of marijuana. Later weekday and weekend bedtimes, but not weekday or weekend sleep duration, showed similar associations across the 3 substance outcomes at baseline. Greater baseline eveningness was also prospectively associated with greater bingeing and past-year use of marijuana at the 1-year follow-up, after covarying for baseline bingeing and marijuana use. Later baseline weekday and weekend bedtimes, and shorter baseline weekday sleep duration, were similarly associated with greater bingeing and past-year use of marijuana at the 1-year follow-up after covarying for baseline values.

CONCLUSIONS

Findings suggest that eveningness and sleep timing may be under recognized risk factors and future areas of intervention for adolescent involvement in alcohol and marijuana that should be considered along with other previously identified sleep factors such as insomnia and insufficient sleep.

Can the circadian phase be estimated from self-reported sleep timing in patients with Delayed Sleep Wake Phase Disorder to guide timing of chronobiologic treatment?

INTRODUCTION

The efficacy of bright light and/or melatonin treatment for Delayed Sleep Wake Phase Disorder (DSWPD) is contingent upon an accurate clinical assessment of the circadian phase. However, the process of determining this circadian phase can be costly and is not yet readily available in the clinical setting. The present study investigated whether more cost-effective and convenient estimates of the circadian phase, such as self-reported sleep timing, can be used to predict the circadian phase and guide the timing of light and/or melatonin treatment (i.e. dim-light melatonin onset, core body temperature minimum and melatonin secretion mid-point) in a sample of individuals with DSWPD.

METHOD

Twenty-four individuals (male = 17; mean age = 21.96, SD = 5.11) with DSWPD were selected on the basis of ICSD-3 criteria from a community-based sample. The first 24-hours of a longer 80-hour constant laboratory ultradian routine were used to determine core body temperature minimum (cBT^min), dim-light melatonin onset (DLMO) and the midpoint of the melatonin secretion period (DLM^mid = [DLM°^ff-DLMO]/2). Prior to the laboratory session subjective sleep timing was assessed using a 7-day sleep/wake diary, the Pittsburgh Sleep Quality Index (PSQI), and the Delayed Sleep Phase Disorder Sleep Timing Questionnaire (DSPD-STQ).

RESULTS

Significant moderate to strong positive correlations were observed between self-reported sleep timing variables and DLMO, cBT^min and DLM^mid. Regression equations revealed that the circadian phase (DLMO, cBT^min and DLM^mid) was estimated within ±1.5 hours of the measured circadian phase most accurately by the combination of sleep timing measures (88% of the sample) followed by sleep diary reported midsleep (83% of the sample) and sleep onset time (79% of the sample).

DISCUSSION

These findings suggest that self-reported sleep timing may be useful clinically to predict a therapeutically relevant circadian phase in DSWPD.

The etiology of delayed sleep phase disorder

According to classification manuals for sleep disorders, nine disorders are directly related to biological clock timing misalignments. Of all, delayed sleep phase disorder (DSPD) is the most commonly diagnosed, predominantly affecting adolescents, young adults, and insomnia patients. It is a persistent inability to fall asleep at earlier, more desirable and socially conventional times, coupled with extreme difficulty awakening in the morning. Considerable evidence shows a delay in the circadian clock to be associated with DSPD. Therefore, treatments have mainly focused on advancing the biological clock and sleep timing through pharmacotherapy, phototherapy and behavioral therapies. The clinical evidence indicates that these treatments are efficacious, at least in the short term. However, follow up studies show frequent patient relapse, leading researchers to speculate that alternative etiologies may be contributing to sleep and circadian clock delays in DSPD. The aim of the present paper is to review and collate current literature related to DSPD etiology in order to outline gaps in current knowledge and suggest future research.