Pilot study of a mindfulness-based, multi-component, in-school group sleep intervention in adolescent girls

The associations among sleep-related difficulties, anxiety, and error-related brain activity in youth

Given the high prevalence of anxiety disorders and their associated impairment, elucidating neural mechanisms related to these disorders has been increasingly prioritized. The error-related negativity (ERN) has been identified as a neural marker that indexes risk for anxiety across development. The ERN seems to confer risk for developing anxiety, especially in the context of stressful life events. The present study sought to examine sleep-related difficulties as another stressful factor that might impact the ERN. In a sample of 221 girls, aged 8 to 15 years old, we first examined the relationship between longer-term (i.e., over the past month) and shorter-term (i.e., over the past week) sleep difficulties and the ERN. We then investigated whether specific sleep difficulties uniquely predict the ERN. In exploratory analyses, we assessed whether sleep difficulties moderate the relationship between the ERN and anxiety. Results indicated that youth who report longer-term lower sleep duration, longer-term worse sleep, and shorter-term lower sleep duration on school days over the past week have a larger (i.e., more negative) ERN. Additionally, only shorter-term sleep duration on school days over the past week uniquely predicted the ERN. Finally, an elevated ERN predicted greater clinical anxiety in the context of longer-term sleep difficulties. Future studies should clarify the direction of these associations via longitudinal designs.

Behavioral Treatment of Insomnia and Sleep Disturbances in School-Aged Children and Adolescents

Insomnia and related sleep disturbances are prevalent among youth and are associated with adverse consequences, including poorer psychiatric functioning. Behavioral sleep interventions, ranging from brief educational interventions to behavioral therapies (cognitive behavior therapy-insomnia), are associated with positive outcomes for pediatric sleep health. In addition, sleep interventions may improve psychiatric health for children and adolescents with neurodevelopmental and internalizing disorders. Additional research is necessary to clarify the efficacy of these interventions over the long-term and across demographic groups; however, evidence suggests incorporating behavioral sleep strategies may prove beneficial to pediatric patients with sleep disturbances and related psychiatric complaints.

Combining participatory action research with intervention mapping to develop and plan the implementation and evaluation of a healthy sleep intervention for adolescents

Background

Adolescents' sleep deteriorated over the last decades, urging the need to develop effective interventions. Using participatory action research (PAR) is a promising and unique approach to target adolescents' sleep. This study aims to describe the process and results of combining PAR and intervention mapping (IM) to guide future researchers on developing and planning of the implementation and evaluation of interventions promoting healthy sleep in adolescents.

Methods

In each of three intervention schools (two with general and technical education and one with technical and vocational education), an action team including adolescents (age 13- 15 years, n=max. 12) and a researcher was composed to develop and plan the intervention. During weekly sessions (n=ranging from 23 to 34 per school), the action team went through the six steps of IM. A short PAR was performed with parents (n=7) to develop parental intervention components.

Results

Combining PAR and IM resulted in interventions focusing on the importance of healthy sleep, regular sleep patterns and associated behaviors: screen behaviors, physical activity, dietary behavior and relaxation. Several differences in the participatory process (i.e. more guidance needed during brainstorms in the vocational/technical school) and developed intervention (i.e. less intrusive intervention components in the vocational/technical school) were observed between schools.

Conclusion

Combining PAR with IM resulted in more extensive interventions than other existing school-based sleep interventions. Future studies should investigate whether a participatory developed sleep intervention could be transferred to another setting using a shorter participatory process.

Tailoring cognitive behavioural therapy for insomnia across contexts, conditions, and individuals: What do we know, where do we go?

Cognitive behavioural therapy for insomnia (CBT-I) is considered the front-line treatment for insomnia. Despite the demonstrated effectiveness of CBT-I, it is necessary to consider how CBT-I may be tailored to different individuals. The purpose of the present review is to provide a summary of literature on tailoring CBT-I to different individuals and provide directions for future research. This review focused on the following domains of adaptation: (i) tailoring CBT-I components to individuals with comorbid mental or physical health conditions such as comorbid depression and pain; (ii) adapting CBT-I delivery for different contexts in which individuals exist, such as inpatient, educational, and different social/cultural settings, (iii) adapting CBT-I to specific individuals via case-formulation in clinical settings. We highlight current gaps in the exploration of tailored CBT-I, including a lack of research methodology to evaluate tailored interventions, a need for the integration of ongoing individualised assessment to inform treatment, and the necessary involvement of consumers and stakeholders throughout the research and treatment development process. Together, this review showed abundant adaptations in CBT-I already exist in the literature. Future research is needed in understanding when and how to apply adaptations in CBT-I and evaluate the benefits of these adaptations.

Lace Up and Mindfulness: A Randomized Controlled Trial Intervention to Reduce Emotional Eating, Anxiety, and Sleep Disturbances in Latinx and Black Youth

This study assessed the effects of a 12-week afterschool mindfulness-based diet and exercise intervention on mental and physical health in Latinx and Black youth. One hundred forty-eight boys and girls (average age = 10.1 years, SD = 1.3 years; 52% girls; 72.3% Latinx) were randomized to either the experimental group (n = 80) or the control group (n = 68). The experimental group participants engaged in fitness yoga, kickboxing, and/or spinning sessions, and mindfulness practices (e.g., breathing, meditation, and mindful eating) twice per week for 12 weeks. The control group participants engaged in a recreational play session once per week for 12 weeks. All participants completed surveys (demographics, acculturation, anxiety, emotional eating, sleep, and food intake) and had their height, weight, and percent body fat measured pre- and post-intervention. Participants wore an accelerometer for 7 days pre- and post-intervention. Repeated measures analysis of covariance indicated that the experimental group participants reported lower scores in emotional eating, anxiety, and sleep latency post-intervention compared to the control group participants. Conversely, no significant differences were observed in physical activity between the experimental and control group participants post-intervention. These findings indicate that a mindfulness-based intervention has a positive effect on emotional eating, anxiety, and sleep latency among youth of color.

Mind-Body Integrative Health (MBIH) Interventions for Sleep among Adolescents: A Scoping Review of Implementation, Participation and Outcomes

Adolescents get insufficient sleep, adversely affecting health. Mind-body integrative health interventions for adolescents have been shown to reduce stress, a barrier to good sleep. This scoping review aimed to synthesize mind-body integrative health interventions for adolescents, how interventions were implemented, who was reached. A systematic search of four online databases was conducted. Randomized, quasi-experimental, and single-group designs with participants ages 10-24 years were included. Twelve studies covering 10 interventions using mindfulness, qigong, aromatherapy, or yoga were identified. Participants were predominantly female; only one study reported participants' race or ethnicity (81% non-Hispanic white). Most (n=6) interventions were delivered in groups, and half reported significant improvements in subjective sleep quality. Mindfulness-based stress reduction and mindfulness-based cognitive therapy were the most commonly used modalities, with reported impact on sleep outcomes measured objectively. The two interventions that found statistically significant, moderate improvements in objectively-measured sleep onset latency and sleep efficiency were of higher intensity and used mindfulness. Four interventions were self-directed; participants in these struggled with adherence; significant impacts on sleep were not found. While findings were mixed, stemming in part from the quality of the underlying studies, this review identified several promising features of interventions, including using mindfulness, ensuring sufficient intervention dose, and targeting interventions towards adolescents with poor sleep at baseline (rather than a general population of adolescents). The findings suggests that sleep interventions for adolescents may improve psychological well-being as an intermediate effect, as sleep improvements were observed mostly among participants with poor sleep quality or anxiety symptoms at baseline. This review identified several gaps in the literature. Despite documented racial and ethnic disparities in sleep quality among adolescents, published evidence of mind-body integrative health-based sleep interventions among Black and Latinx adolescents is lacking. None of the studies in this review assessed developmental stage or age differences, despite documented differences in sleep across age groups of adolescents. These two gaps in the evidence should be addressed in future intervention research.

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.

What time do you plan to sleep tonight? An intense longitudinal study of adolescent daily sleep self-regulation via planning and its associations with sleep opportunity

BACKGROUND

Most adolescents are sleep deprived on school days, yet how they self-regulate their sleep-wake behaviours is poorly understood. Using ecological momentary assessment, this intense longitudinal study explored patterns of adolescents' daily bedtime and risetime planning and execution, and whether these behaviours predicted sleep opportunity.

METHODS

Every afternoon, for 2 school weeks and the subsequent 2 vacation weeks, 205 (54.1% female, 64.4% non-White) adolescents from year 10 to 12 (M ± SD_age  = 16.9 ± 0.9) reported their plans for bedtime (BT) that evening, and for risetimes (RT) the following day. Actual daily sleep was measured via actigraphy and sleep diary.

RESULTS

Some adolescents never planned bedtime (school 19.5%, non-school 53.2%) or risetime (school 1.5%, non-school 24.4%). More adolescents planned consistently (≥75% of days) on school (BT = 29.9%, RT = 61.3%) compared to non-school nights (BT = 3.5%, RT = 2.5%). On average, adolescents went to bed later than planned, with longer delays on non-school (71 min) compared to school nights (46 min). Of those who executed their plans within ≤15 min, more did it consistently (≥75% of days) on school (BT = 40.9%, RT = 67.7%) than on non-school nights/days (BT = 29.7%, RT = 58.6%). Mixed effects models utilizing daily data, controlling for sex, race, and study day, showed that bedtime planning predicted longer time in bed (TIB; p < .01) on school and shorter TIB on non-school nights (p < .01); and greater delay in actual (compared to planned) BT predicted shorter TIB (p < .001).

CONCLUSIONS

Adolescents may require support during the transition from parent-controlled to autonomous sleep self-regulation. Bedtime planning on school nights and going to bed as planned are two modifiable sleep regulatory behaviours that are protective and potential therapeutic targets for increasing sleep opportunity in adolescents.

Impact of a Behavioral Sleep Intervention in Adolescents With ADHD: Feasibility, Acceptability, and Preliminary Effectiveness From a Pilot Open Trial

OBJECTIVE

An open trial tested the feasibility, acceptability, and preliminary effectiveness of a behavioral sleep intervention in adolescents with ADHD.

METHOD

Fourteen adolescents (ages 13-17 years; 50% male) with ADHD and co-occurring sleep problems received the cognitive-behavioral-based Transdiagnostic Sleep and Circadian Intervention for Youth (TranS-C). Adolescent, parent, and teacher ratings, actigraphy, and daily sleep diaries were collected at pre-intervention, post-intervention, and 3-month follow-up.

RESULTS

Adolescents experienced moderate to large improvements in sleep, mental health symptoms, and daily life executive functioning from pre-treatment to post-treatment, and improvements were generally maintained at 3 months. Pre-intervention, 71.4% of adolescents were classified as poor sleepers and this was reduced to 21.4% and 28.6% at post-treatment and follow-up, respectively.

CONCLUSION

This study provides strong preliminary evidence that TranS-C improves sleep and associated outcomes in adolescents with ADHD and co-occurring sleep problems. A randomized controlled trial is needed to rigorously test the efficacy of TranS-C in this population.

Effectiveness of a Mindfulness-Based Group Intervention for Chinese University Students with Sleep Problems

The increasing prevalence of sleep disorders among university students should be taken seriously. Group counseling involving a mindfulness-based strategy may help prevent students from developing insomnia and subsequent mental health disorders. This study aimed to evaluate the ameliorating effects of a mindfulness-based group intervention on sleep problems and emotional symptoms in university students in China. Twenty-one university students (16 females, 22.71 ± 4.28 years) who were not on medication were recruited and assigned to the intervention group based on the criterion of high levels of sleep problems. Additionally, twenty-four university students (19 females, 24.50 ± 0.93 years) were included as a nonrandomized control group. Individuals in the intervention group participated in a two-hour group intervention once a week for eight sessions. All participants completed self-reported questionnaire baseline tests, postintervention tests, and one-month follow-ups on mindfulness, sleep quality, anxiety and depressive symptoms. Repeated-measures ANOVA was performed. The results revealed significant intervention effects, with significant differences observed between the two groups in mindfulness and sleep quality. However, there was no significant effect of the intervention on anxiety and depressive symptoms. This study contributes to a better understanding of the effectiveness of mindfulness-based intervention in addressing sleep problems in university students.

Sleep problems predict next-day suicidal thinking among adolescents: A multimodal real-time monitoring study following discharge from acute psychiatric care

Suicidal thoughts and behaviors (STBs) are major public health concerns among adolescents, and research is needed to identify how risk is conferred over the short term (hours and days). Sleep problems may be associated with elevated risk for STBs, but less is known about this link in youth over short time periods. The current study utilized a multimodal real-time monitoring approach to examine the association between sleep problems (via daily sleep diary and actigraphy) and next-day suicidal thinking in 48 adolescents with a history of STBs during the month following discharge from acute psychiatric care. Results indicated that specific indices of sleep problems assessed via sleep diary (i.e., greater sleep onset latency, nightmares, ruminative thoughts before sleep) predicted next-day suicidal thinking. These effects were significant even when daily sadness and baseline depression were included in the models. Moreover, several associations between daily-level sleep problems and next-day suicidal thinking were moderated by person-level measures of the construct. In contrast, sleep indices assessed objectively (via actigraphy) were either not related to suicidal thinking or were related in the opposite direction from hypothesized. Together, these findings provide some support for sleep problems as a short-term risk factor for suicidal thinking in high-risk adolescents.

Treatment Implications of Sleep-Related Problems in Pediatric Anxiety Disorders: A Narrative Review of the Literature

Pediatric anxiety disorders and sleep-related problems (SRPs) are highly prevalent and are associated with serious health or psychopathological consequences. This narrative review aims to provide an overview of the current evidence of the associations between anxiety disorders and SRPs, to examine how this relationship may affect treatment, and to evaluate future directions for the field. Despite their strong bi-directional relationship, SRPs are often neglected in pediatric anxiety literature. There is little consensus on the conceptualization and related measurements of SRPs, which has led to methodological limitations and difficulties. Furthermore, available research suggests that anxiety treatment alone may be inadequate as clinically impairing SRPs were still present post-treatment, which may, in turn, diminish effects of therapy. Understanding the implications of the relationship between anxiety and SRPs on treatment outcomes may be helpful in recognizing opportunities for high impact and enduring interventions.

Designing adolescent sleep interventions with stakeholder input

OBJECTIVE

Few sleep promotion programs for adolescents have involved stakeholders as part of the intervention development, which may contribute to their limited accessibility, scalability, acceptability, and feasibility. Specifically asking stakeholders for their input on how to modify factors impacting sleep is critical, as is identifying strategies for motivating sleep behavior change. We report qualitative feedback from stakeholders interested in improving adolescent sleep, data collected specifically to inform the development of an adolescent sleep promotion program.

PARTICIPANTS

We conducted 9 focus groups (3 each for young adults (n = 8, ages 21-25), parents of adolescents (n = 12), and healthcare providers working with adolescents (n = 29) following a semistructured approach.

DESIGN

Participants reported on contributors to good and poor sleep; motivators for improving sleep; strategies for promoting and sustaining behavior change; and feasibility of a proposed sleep promotion program. We coded and thematically analyzed focus group transcripts using inductive and deductive approaches.

RESULTS

Moderate engagement in activities (eg, a job, sports) was seen as a contributor to good sleep, while having too many or too few activities was thought to contribute to poor sleep. Linking improved sleep with personalized outcomes of interest can enhance motivation for changing sleep. Strategies for behavior change should rely on increasing internal motivation, personalizing intervention content, and having parents model desired behaviors.

CONCLUSIONS

Key stakeholders are critical to the development of acceptable interventions that can be implemented effectively in real-world settings. Future work should test whether the identified themes contribute to increased feasibility, scalability, and effectiveness of sleep programs.

Psychosocial stress, sleep quality and interest in mind-body integrative health sleep intervention among urban adolescents in the school-based health setting

BACKGROUND

Mind-body integrative health (MBIH) interventions to improve adolescent sleep are lacking. The study characterized sleep quality and bedtime-related psychosocial stressors among urban minority adolescents, explored associations between demographics factors, stressors and sleep quality, and gauged interest in a MBIH sleep intervention.

MATERIALS AND METHODS

167 school-based health center (SBHC) patients (mean age = 16.3; 64 % female; 68 % Latino) participated in a needs assessment as part of a quality improvement project. They reported bedtime-related psychosocial stressors using items from the Adolescent Sleep Hygiene Scale (ASHS), sleep quality using the Pittsburgh Sleep Quality Index (PSQI), and interest in a MBIH-based sleep intervention. Chi-square and logistic regression examined associations between demographics, stressors, sleep quality, and interest in the intervention.

RESULTS

67 % had poor sleep quality. Females, compared to males, had 2.23 higher odds (95 % Confidence Interval [CI]: 1.12, 4.42) of having poor sleep quality. Nearly 80 % experienced bedtime-related stressors (25 % experienced one stressor, 17 % two stressors and 37 % three or more stressors); relative to those reporting no stressors, those reporting 3+ stressors had 3.15 higher odds (95 % CI: 1.27, 7.84) of having poor sleep quality. Most (77 %) reported they would participate in an SBHC-based intervention that utilized MBIH modalities preferring both one-on-one and group sessions.

CONCLUSIONS

Urban, predominantly Hispanic and Black, SBHC adolescent patients have poor sleep quality and report bedtime-related psychosocial stressors. Their interest in MBIH interventions to address sleep problems represents a unique opportunity for practitioners and complementary therapists to offer MBIH interventions to a population at high-risk for poor sleep quality.

The need for sleep and circadian education in Australian high schools: incidental results from a survey of university students

ISSUE ADDRESSED

To describe the need for high school sleep education from the perspective of undergraduate university students.

METHODS

Undergraduate students who completed an online course on sleep and circadian health were surveyed 6 months after course completion. Students were asked whether a similar course would have benefited them as high school students, and about the need for sleep education in high schools. Thematic analysis of this qualitative data was carried out.

RESULTS

Eighty-nine students who had attended 71 unique high schools provided responses. Eight-one per cent thought they would have benefitted from a similar course during high school and identified domains of sleep knowledge particularly relevant to high school students. They cited environmental barriers to healthy sleep present during high school and believed that sleep education could improve students' lifestyle, sleep and performance. Nineteen per cent of students said they would not have benefited, because they perceived sleeping patterns during high school to be nonmodifiable or believed that previous sleep education was sufficient. Of the respondents who did not think students would benefit, 53% would still tell their high school principal that there was a need for sleep education.

CONCLUSIONS

The findings support the need for engaging sleep education for high school students. Future studies should examine the perspectives of students in high school directly, rather than undergraduate students who have already shown an interest in sleep health. SO WHAT?: Sleep health is missing from the Australian school curriculum. Online courses may be an engaging method of promoting sleep and circadian health to high school students.

Update on school-based sleep education programs: how far have we come and what has Australia contributed to the field?

OBJECTIVE

School-based sleep education programs help to promote sleep health information to many children and adolescents. The aim of this systematic review was to identify and describe school-based sleep education programs, to update previous reviews and identify recent advances and improvements in this field worldwide.

METHODS

Four electronic databases were searched. Eligibility criteria included children aged 5-18 years, sleep education intervention conducted in a school setting, and at least one pre-post-measure of a sleep variable.

RESULTS

A total of 32 articles met eligibility criteria with Australian sleep researchers constituting ∼ one quarter of these studies. Studies dated from 2007 to 2020 with sample sizes ranging from 9 to 3713 students. The majority of participants were high school students and predominantly female. Education programs generally took 4-6 weeks and content was consistent across studies. Overall, exposure to sleep education increased sleep knowledge, however changes in sleep behaviour variables and secondary outcome variables (eg, mental health; cognitive function; sleep hygiene practices) presented varied results. Studies conducted since 2015 were more likely to be randomised controlled trials and to include more interactive, online designs utilising innovative content such as mindfulness.

CONCLUSIONS

An exponential growth in school sleep education programs was identified since 2016. Future studies should consider utilising objective sleep measures, longer-term follow-ups, innovative delivery methods, and stronger attempts at implementing a knowledge-to-action approach for more sustainable programs.

Review: Delivering mental health support within schools and colleges - a thematic synthesis of barriers and facilitators to implementation of indicated psychological interventions for adolescents

BACKGROUND

Increasing the role of schools and colleges in the provision of mental health services for young people has the potential to improve early intervention and access to treatment. We aimed to understand what factors influence the successful implementation of indicated psychological interventions within schools and colleges to help guide increased provision of mental health support within education settings.

METHODS

Systematic search for studies that have reported barriers or facilitators to the implementation of indicated interventions for adolescent emotional disorders delivered within schools and further education/sixth form colleges (CRD42018102830). Databases searched were EMBASE, MEDLINE, PsycINFO, CINAHL, British Nursing Index, ASSIA, ERIC and British Education Index. A thematic synthesis of factors reported to impact implementation was conducted.

RESULTS

Two thousand five hundred and sixty-nine records and 177 full texts were screened. Fifty studies were identified for inclusion, all of which were of school-based interventions. Eleven analytic themes were developed encompassing intervention characteristics, organisational capacity, training and technical assistance, provider characteristics and community-level factors. Findings indicate the need to select appropriate interventions, consider logistical challenges of the school context and provide training and supervision to enable staff to deliver interventions with fidelity. However, structural and environmental support is required for these facilitators to have the greatest impact on successful implementation.

CONCLUSIONS

Implementing indicated school-based mental health interventions is challenging. Those involved in planning school-based mental health initiatives must be alert to the impact of factors on multiple interacting levels. There is a lack of research on implementing mental health support within further education and sixth form colleges.

KEY PRACTITIONER MESSAGE

Increased utilisation of schools and colleges as a setting for early intervention has been proposed as a means of improving access to mental health treatment, but successful implementation of mental health interventions within educational settings is challenging. Based on a synthesis of current evidence, we recommend that young people and education professionals should be involved in the selection of school-based interventions to ensure they are acceptable and practical to deliver within the logistical constraints of the school environment. Those delivering interventions within schools, as well as staff involved in identifying young people who might benefit from these interventions, must receive high-quality ongoing training and support. Senior school leaders play an important role in championing mental health interventions and developing a school culture that prioritises mental well-being. Health and education policy should be designed to promote a cross-sector focus on the emotional health of young people. There is a lack of evidence on the implementation of indicated psychological interventions within sixth form and further education colleges.

Sleep among Youth with Severely Disabling Chronic Pain: Before, during, and after Inpatient Intensive Interdisciplinary Pain Treatment

Poor sleep is commonly reported in pediatric chronic pain. There are signals that intensive interdisciplinary pain treatments (IIPT) may inadvertently improve objective sleep, but this claim cannot be substantiated without baseline sleep data prior to IIPT. This study followed the objective sleep/wake patterns (e.g., duration, quality, timing, consistency) of pediatric patients with severely functionally disabling chronic pain before, during, and after inpatient IIPT (the Functional Independence Restoration Program-"FIRST Program"), alongside a similarly-disabled chronic pain Comparison Group. The final sample included N = 10 FIRST Patients and N = 9 Comparison Group patients. At baseline, the whole sample showed healthy sleep duration (~9 h), average sleep efficiency <90%, late sleep onset and offset (mean = 11:56 p.m.-8:50 a.m.), and highly inconsistent sleep schedules night to night. During IIPT, FIRST Patients maintained healthy sleep durations, moved sleep schedules 2 h earlier, and decreased timing and duration variability by >60 min while the Comparison Group maintained similar sleep to baseline. At follow up (1-2 months later), FIRST Patients' sleep schedules shifted later but were still less variable than at baseline. Results point to the malleability of sleep/wake patterns within treatment contexts with strict environmental control but suggest that these gains may be difficult for youth with chronic pain to maintain in the home environment.

Behavioral Treatment of Insomnia and Sleep Disturbances in School-Aged Children and Adolescents

Insomnia and related sleep disturbances are prevalent among youth and are associated with adverse consequences, including poorer psychiatric functioning. Behavioral sleep interventions, ranging from brief educational interventions to behavioral therapies (cognitive behavior therapy-insomnia), are associated with positive outcomes for pediatric sleep health. In addition, sleep interventions may improve psychiatric health for children and adolescents with neurodevelopmental and internalizing disorders. Additional research is necessary to clarify the efficacy of these interventions over the long-term and across demographic groups; however, evidence suggests incorporating behavioral sleep strategies may prove beneficial to pediatric patients with sleep disturbances and related psychiatric complaints.

Seeing the Whole Elephant: a scoping review of behavioral treatments for pediatric insomnia

Pediatric insomnia is common, impacting up to a third of typically-developing, healthy children, and over 80% of children with neurodevelopmental disorders or chronic medical conditions. Previous reviews of behavioral interventions for pediatric insomnia have had a limited focus on a single age group, a specific population, and/or only randomized controlled trials. Furthermore, few reviews have considered non-sleep outcomes of both children and their parents. This scoping review provides a broader context, including studies regardless of research design or population, along with sleep and non-sleep study outcomes. Clear gaps in the literature were identified, highlighting the need for additional research in different populations, including school-age children and adolescents, racial/ethnic groups around the world, as well as youth with medical or psychiatric disorders. In addition, more research is needed on different features of treatment, including the delivery mode, involvement of all family members, non-sleep outcomes, and long-term follow-up.

The Teensleep study: the effectiveness of a school-based sleep education programme at improving early adolescent sleep

Objective

To evaluate the impact of a school-based sleep education programme on adolescent sleep and sleep knowledge.

Methods

This is the first outcome report on ‘Teensleep’: a novel, teacher-led programme, comprising ten lessons that can be delivered flexibly. Students in Year 10 (n = 1504; mean age = 14.14 ± 0.35 years) from ten UK state (non-fee-paying) secondary schools received the lessons and parents received a leaflet. Effectiveness was assessed using measures across two time points (pre- and post-intervention). Students completed questionnaires on sleep knowledge, sleep quality, sleep behaviour, sleep hygiene, daytime sleepiness and health-related quality of life. A sub-sample provided objective (actigraphy, n = 84) and subjective (sleep diary, n = 74) sleep measures.

Results

Large improvements in sleep knowledge (d = 0.78), and smaller improvements in sleep quality (d = 0.15) and sleep hygiene (d = 0.11) were observed, but not in daytime sleepiness or health-related quality of life. Small and limited changes in subjective and objective sleep patterns were found. Baseline sleep quality was differentially associated with key outcomes, with those initially self-reporting poor sleep demonstrating an improvement in sleep quality, sleep hygiene and sleepiness.

Conclusion

Teensleep was effective at improving sleep knowledge but sleep changes were small. Such interventions have traditionally focused on gains for all students, but this study suggests that poor sleepers may be the most likely to experience immediate direct sleep benefits. Follow-up studies are required to investigate whether or not sleep education provides long-term benefits as a step towards preventative sleep medicine.

•

‘Teensleep’ is a teacher-led, school-based sleep education programme for adolescents.

•

Large-scale study: students received lessons in ten UK schools.

•

Programme effectiveness was evaluated using questionnaires and actigraphy.

•

Sleep knowledge, self-reported sleep quality and sleep hygiene improved after lessons.

•

Study suggests poor sleepers may be most likely to experience immediate benefits.

Low-intensity sleep intervention in a youth mental health service: a case series analysis

BACKGROUND

There is increasing evidence of a strong association between sleep and mental health in both adolescents and adults. CBT for insomnia is being applied to good effect with adults with mental health difficulties but there are few studies examining its applicability to adolescents within mental health services.

METHOD

We carried out a case series analysis (n = 15) looking at the feasibility, accessibility and impact of a low-intensity sleep intervention for young people (14-25 years) being seen by a secondary care Youth Mental Health team in the UK. The intervention was based on cognitive behavioural therapy for insomnia (CBTi) and acceptance and commitment therapy (ACT) approaches and involved six individual sessions delivered on a weekly basis by a graduate psychologist. Routine outcome measures were used to monitor insomnia, psychological distress and functioning with assessments at baseline, session 3, session 6 and at 4 weeks after end of intervention. All participants scored in the clinical range for insomnia at the start of the study.

RESULTS

High uptake, attendance and measure completion rates were observed. Large effect sizes were observed for insomnia, psychological distress and functioning. Twelve of the fifteen participants (80%) no longer scored above threshold for insomnia at follow-up. All seven under-18s no longer met threshold for clinical 'caseness' on the Revised Child Anxiety and Depression Scale (RCADS) at follow-up.

DISCUSSION

The findings suggest that the intervention was well accepted by young people and feasible to apply within a secondary care setting. Strong effect sizes are encouraging but are probably inflated by the small sample size, uncontrolled design and unblinded assessments.

Effectiveness of mindfulness-based interventions on anxiety for children and adolescents: A systematic review and meta-analysis

AIM

This paper aims to investigate the extent to which mindfulness-based interventions serve to reduce anxiety in children and adolescents. A heterogeneous sample was used, including clinical and non-clinical population.

METHODS

A literature search of controlled intervention studies published up to December 31, 2016, was carried out in PubMed, Lilacs, Cochrane, Embase, PsycInfo, Opengrey and Teseo databases. The effect size was calculated by Cohen's d. The Cochran Q statistic and the I² index were used for the study of heterogeneity. An analysis was conducted using the random effects model.

RESULTS

829 articles were identified, of which 18 were finally selected. Of these, only three had statistically significant effect sizes. The overall combined result obtained was .013, but it did not result statistically significant (CI95% [-.102, .128].) The Q statistic was statistically significant (Q [18] = 28.497, P = . 39) and the I² index was 40.34%, indicating a moderate heterogeneity.

CONCLUSIONS

This meta-analysis did not obtain statistically significant results that could provide conclusions. In general, the studies analysed are small, of low power and have a marked heterogeneity, which implies that the findings are provisional and need to be supported by more robust studies. Although it cannot be ruled out that mindfulness-based interventions are not effective in the infant-juvenile population, it is also possible that this effect could not be detected due to the limited number of available studies. Larger investigations are needed, with sufficient statistical power and designs that control the variables potentially moderating, to establish clear conclusions.

Sleep in relation to psychiatric symptoms and perceived stress in Swedish adolescents aged 15 to 19 years

BACKGROUND

Sleep affects psychiatric health and perceived stress during adolescence.

OBJECTIVE

The first aim of this study was to investigate the prevalence of poor sleep in a sample of Swedish adolescents aged 15 to 19 years. The second aim was to investigate correlations between: a) sleep and psychiatric symptoms and; b) sleep and perceived stress. The third aim was to examine possible sex differences in sleep.

METHOD

In 2011, a total of 185 Swedish adolescents (aged 15 to 19 years) from two upper secondary schools participated in this cross-sectional study. We used three different psychometric scales: Pittsburgh Sleep Quality Index (PSQI), Symptoms Checklist (SCL-90), and Perceived Stress Scale (PSS) to measure sleep, general psychiatric health and perceived stress.

RESULTS

In total, 76% of the female students and 71% of the male students had poor overall sleep quality. A large majority, 93%, reported daytime dysfunction and 60% reported problems staying awake during daily activities. The correlation between sleep and general psychiatric health was 0.44 and the correlation between sleep quality and perceived stress was 0.48. Female students reported significantly more sleep disturbances than male students do.

CONCLUSIONS

Three out of four of the upper secondary school students presented with poor overall sleep that associated with psychiatric symptoms and perceived stress. These findings add to results from earlier studies and imply that interventions to improve sleep in adolescents, individually as well as on a societal level, should be considered as one way of trying to impact the observed rising numbers of psychiatric complaints. Such interventions may improve mental and somatic health in adolescents and prevent the development of psychiatric and stress-related symptoms. Further studies of possible methods, and their implementation, for improving sleep in adolescents should be of high priority.

A Review of Pediatric Nonpharmacological Sleep Interventions: Effects on Sleep, Secondary Outcomes, and Populations With Co-occurring Mental Health Conditions

Sleep problems are common in school-age children and linked to numerous negative outcomes. Sleep disturbances are particularly common in children with mental health disorders, such as attention-deficit/hyperactivity disorder, depression, and anxiety. Despite frequent use of nonpharmacological pediatric sleep interventions to treat common sleep problems, there is a paucity of research on whether these interventions are effective. Further, it is unclear whether by targeting sleep, these interventions lead to broader improvements in the domains of functioning that are commonly affected by poor sleep. The present review includes 20 studies that evaluated nonpharmacological sleep treatments for school-aged youth, including 5 studies specifically focused on youth with externalizing or internalizing problems. Multimodal approaches consisting of psychoeducation and sleep hygiene in combination with other components were effective at treating insomnia and general sleep problems in typically developing samples. The addition of behavioral parent training to sleep interventions was effective for youth with externalizing problems, whereas incorporating cognitive strategies into sleep interventions for youth with internalizing problems was found to be ineffective. A variety of secondary outcomes were examined, with the strongest support emerging for improvement in anxiety and behavioral problems. Implications for clinical practice and future research directions are discussed.

(Re)Conceptualizing Sleep Among Children with Anxiety Disorders: Where to Next?

Children with anxiety disorders (AD) characteristically complain of sleep problems and the extent to which cognitive behavioral treatments (CBT) for childhood anxiety produce sleep-based improvements is a topic of increasing interest. The current paper reviews available evidence for subjective sleep complaints and objective sleep alterations in children and adolescents with AD, including investigations of potential changes in sleep following anxiety-focused CBT. Despite pervasive complaints of poor sleep, the empirical literature provides minimal evidence for actual sleep-wake alterations in this population of youth and evidence for sleep-based changes following treatment for anxiety is minimal. In line with calls for more comprehensive models of the role of sleep in developmental psychopathology, several fundamental gaps in understanding are described and highlighted as essential avenues for clarifying the nature and consequences of poor quality sleep among youth with clinical levels of anxiety. In a second section of the paper, an emerging body of novel, translational research investigating more intricate sleep-anxiety relationships is introduced with potential implications for both etiological models and treatment design and delivery.

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.

Positive and Negative Emotions: Differential Associations with Sleep Duration and Quality in Adolescents

Despite positive and negative emotions being equally important predictors of adolescent wellbeing, research examining positive emotions is limited. In 4582 adolescents (69.4% females; age M ± SD = 14.55 ± 1.74 years), we used structural equation modelling to examine associations between self-reported sleep duration and quality with positive affect, negative affect, and happiness, controlling for age and sex. Overall, sleep quality displayed stronger associations with all measures of emotions compared to sleep duration. Shorter sleep was more specifically associated with lower positive emotions (happiness, followed by positive affect), whereas poorer sleep showed stronger associations with negative affect. Protecting sleep duration may promote positive emotions and enhancing sleep quality may reduce mood disturbances. Future research could incorporate both positive and negative emotions to better understand adolescents' wellbeing.

Anxiety Treatment and Targeted Sleep Enhancement to Address Sleep Disturbance in Pre/Early Adolescents with Anxiety

Sleep disturbance is prevalent in anxious youth and prospectively predicts poor emotional adjustment in adolescence. Study 1 examined whether anxiety treatment improves subjective and objective sleep disturbance in anxious youth. Study 2 examined whether a sleep intervention called Sleeping TIGERS can further improve sleep following anxiety treatment. Study 1 examined 133 youth (ages 9-14; 56% female; 11% ethnic/racial minority) with generalized, social, or separation anxiety over the course of anxiety treatment (cognitive behavioral treatment or client-centered treatment). Sleep-related problems (parent-, child-report) and subjective (diary) and objective (actigraphy) sleep patterns were assessed across treatment in an open trial design. Study 2 included 50 youth (ages 9-14; 68% female; 10% ethnic/racial minority) who continued to report sleep-related problems after anxiety treatment and enrolled in an open trial of Sleeping TIGERS. Pre- and postassessments duplicated Study 1 and included the Focal Interview of Sleep to assess sleep disturbance. Study 1 demonstrated small reductions in sleep problems and improvements in subjective sleep patterns (diary) across anxiety treatment, but outcomes were not deemed clinically significant, and 75% of youth stayed above clinical cutoff. Study 2 showed clinically significant, large reductions in sleep problems and small changes in some subjective sleep patterns (diary). Anxiety treatment improves, but does not resolve, sleep disturbance in peri-pubertal youth, which may portend risk for poor emotional adjustment and mental health. The open trial provides preliminary support that Sleeping TIGERS can improve sleep in anxious youth to a clinically significant degree.

Insomnia disorder in adolescence: Diagnosis, impact, and treatment

Insomnia disorder is very common in adolescents; it is particularly manifest in older adolescents and girls, with a prevalence comparable to that of other major psychiatric disorders (e.g., depressive disorders). However, insomnia disorder in adolescence is poorly characterized, under-recognized, under-diagnosed, and under-treated, and the reason for the female preponderance for insomnia that emerges after puberty is largely unknown. Insomnia disorder goes beyond an individual complaint of poor sleep or a sleep state misperception, and there is emerging evidence supporting the association of insomnia symptoms in adolescents with alterations in several bio-systems including functional cortical alterations and systemic inflammation. Insomnia disorder is associated with depression and other psychiatric disorders, and is an independent risk factor for suicidality and substance use in adolescents, raising the possibility that treating insomnia symptoms in early adolescence may reduce risk for these adverse outcomes. Cognitive behavioral treatments have proven efficacy for adolescent insomnia and online methods seem to offer promising cost-effective options. Current evidence indicates that insomnia in adolescence is an independent entity that warrants attention as a public health concern in its own right.

Non-pharmacological therapies for sleep disturbances in people with Parkinson's disease: A systematic review

AIM

To determine the effectiveness of non-pharmacological therapies for sleep disturbances in people with Parkinson's disease (PD).

BACKGROUND

Sleep disturbances, which are common in people with PD, may diminish their quality of life. Non-pharmacological therapies are preferred over pharmacological therapies for improving sleep quality, owing to fewer adverse effects.

DESIGN

Systematic literature review.

DATA SOURCES

A systematic search of eight databases and hand searching was conducted for papers published between 1 January 2000 - 1 January 2016.

REVIEW METHODS

The Cochrane methods were followed. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias Tool.

RESULTS

Eight studies were identified for data extraction. Therapeutic domains included physical exercise, cognitive behavioural and complementary interventions. Therapies in four of the eight studies significantly improved sleep quality and the unified PD rating scale score. Other studies showed no clear effects on sleep (N = 1), limited effects on sleep (N = 1) or effects in both the intervention and control groups, indicating that the intervention had no distinctive effects (N = 2).

CONCLUSIONS

The non-pharmacological intervention types and sleep-related measured outcomes were heterogeneous. Most therapies had inconsistent effects on sleep. The insufficient evidence for non-pharmacological treatments seems related to the unique motor-associated clinical features of PD, which restrict the use of physical exercise therapy, or to individual "wearing-off" periods, which limit group therapy. Further studies on non-pharmacological therapies are required to identify the best interventions for improving sleep quality in people with PD.

Factors associated with insomnia and complementary medicine use in children: results of a national survey

OBJECTIVES

Sleep difficulties are a serious health problem in children, and interest in using complementary and alternative medicine (CAM) therapies to treat sleep is growing. In this study, we aimed to identify: the prevalence of sleep difficulties in children, and the prevalence and patterns of CAM use among children with trouble sleeping.

METHODS

We used the 2012 National Health Interview Survey (NHIS) dataset to estimate the prevalence of sleep difficulties and CAM use in children ages 6-17 years. Prevalence estimates were weighted to reflect the survey's sampling design. We used logistic regression to explore associations between sleep difficulties, psychosocial factors, comorbidities and CAM use.

RESULTS

6.4% of children in the 2012 NHIS dataset reported regular difficulty sleeping in the last year, corresponding to an estimated 1.5 million children in the US. Older age, poorer health status, more missed school days, and multiple comorbidities were all associated with sleep difficulties (p ≤ 0.001). Among children with sleep difficulties, 29% used at least one CAM therapy. Of the CAM therapies surveyed, non-vitamin, non-mineral supplements were the most commonly used (14.6%), followed by manipulation therapies (9.2%) and mind-body techniques (8.8%). Parental education and CAM use were most strongly associated with child CAM use (p ≤ 0.001).

CONCLUSIONS

CAM therapies, particularly non-vitamin, non-mineral supplements, are commonly used among children with sleeping problems. More research is needed to characterize the safety and efficacy of CAM therapies for sleep in this population.

Binge Viewing, Sleep, and the Role of Pre-Sleep Arousal

STUDY OBJECTIVES

To investigate the prevalence of binge viewing, its association with sleep and examine arousal as an underlying mechanism of this association.

METHODS

Four hundred twenty-three adults (aged 18-25 years old, 61.9% female) completed an online survey assessing regular television viewing, binge viewing, sleep quality (Pittsburgh Sleep Quality Index), fatigue (Fatigue Assessment Scale), insomnia (Bergen Insomnia Scale), and pre-sleep arousal (Pre-Sleep Arousal Scale). Regression analyses were conducted. Mediation analysis was performed using PROCESS Macro.

RESULTS

There were 80.6% who identified themselves as a binge viewer. Among those who binge viewed (n = 341), 20.2% had binge viewed at least a few times a week during the past month. Among poor sleepers (Pittsburgh Sleep Quality Index > 5), 32.6% had a poor sleep quality associated with being a binge viewer. Higher binge viewing frequency was associated with a poorer sleep quality, increased fatigue and more symptoms of insomnia, whereas regular television viewing was not. Cognitive pre-sleep arousal fully mediated these relationships.

CONCLUSIONS

New viewing styles such as binge viewing are increasingly prevalent and may pose a threat to sleep. Increased cognitive arousal functions as the mechanism explaining these effects. Measures of media exposure should take into account the user's level of engagement with media. Interventions aimed at (1) alerting viewers about excessive viewing duration and (2) reducing arousal before sleep may be useful ways to tackle sleep problems in binge viewers.

School-Based Sleep Education Programs for Short Sleep Duration in Adolescents: A Systematic Review and Meta-Analysis

BACKGROUND

Insufficient sleep among students is a major school health problem. School-based sleep education programs tailored to reach large number of students may be one of the solutions. A systematic review and meta-analysis was conducted to summarize the programs' effectiveness and current status.

METHODS

Electronic databases were searched up until May 2015. Randomized controlled trials of school-based sleep intervention among 10- to 19-year-old students with outcome on total sleep duration were included. Methodological quality of the studies was assessed using the Cochrane's risk of bias assessment.

RESULTS

Seven studies were included, involving 1876 students receiving sleep education programs and 2483 attending classes-as-usual. Four weekly 50-minute sleep education classes were most commonly provided. Methodological quality was only moderate, with a high or an uncertain risk of bias in several domains. Compared to classes-as-usual, sleep education programs produced significantly longer weekday and weekend total sleep time and better mood among students at immediate post-treatment, but the improvements were not maintained at follow-up.

CONCLUSIONS

Limited by the small number of studies and methodological limitations, the preliminary data showed that school-based sleep education programs produced short-term benefits. Future studies should explore integrating sleep education with delayed school start time or other more effective approaches.

Longitudinal relationships of sleep and inhibitory control deficits to early adolescent cigarette and alcohol use

Research in older adolescents suggests insufficient sleep may increase substance use initiation risk. This study tested whether sleep duration and dysregulation of sleep-wake patterns in late-elementary school youth were prospectively associated with cigarette and alcohol use initiation and how sleep-related changes in inhibitory control mediate these relationships. Average sleep duration at 4th grade predicted 6th grade cigarette but not alcohol use, however indirect effects were identified through 5th grade inhibitory control to both cigarette and alcohol use. Indirect effects were also identified through inhibitory control for relationships between 4th grade weekend bed-time delay and 6th grade cigarette or alcohol use, and for relationships between 4th grade weekend wake-time delay and 6th grade cigarette or alcohol use. Reductions in nightly sleep increased risk of cigarette use. Findings suggest a pathway linking both reduced sleep duration and greater weekend shifting of sleep patterns to future substance use through sleep-related inhibitory control deficits.

A Mindfulness-Based Intervention Pilot Feasibility Study for Elementary School Students With Severe Learning Difficulties: Effects on Internalized and Externalized Symptoms From an Emotional Regulation Perspective

OBJECTIVE

Students with severe learning disabilities often show signs of anxiety, depression, and problem behaviors such as inattention and conduct problems. Mindfulness-based interventions (MBIs) in school settings constitute a promising option to alleviate these co-occurring symptoms. This pilot study aimed to evaluate the impact of an MBI on symptoms and behaviors of elementary school students with severe learning disabilities.

METHOD

A one-group pretest-posttest design was used. The sample comprised 14 students aged 9 to 12 years with special education needs. Both student-report and teacher-report of the Behavior Assessment System for Children, Second Edition were used.

RESULTS

Repeated-measures analyses of variance revealed a significant impact of the MBI on symptoms and behaviors such as anxiety, depression, inattention, aggression, and conduct problems. Effect sizes for all variables were considered large (partial η² = .31-.61).

CONCLUSION

These preliminary results indicate that MBIs can reduce the frequency of symptoms and problem behaviors often found in children with learning disabilities in elementary schools. Further multiple baseline experimental trials with a long-term follow-up are warranted to establish more robustly the effect of MBIs for children with learning disabilities.