Lessons Learned from Sleep Education in Schools: A Review of Dos and Don'ts

Racial and ethnic sleep health disparities in adolescents and risk for type 2 diabetes: a narrative review

INTRODUCTION

Sleep is an essential factor for health and wellbeing in people across the age spectrum; yet many adolescents do not meet the recommended 8-10 h of nightly sleep. Unfortunately, habitually insufficient sleep, along with the metabolic changes of puberty, puts adolescents at increased risk for a host of adverse health outcomes such as obesity and type 2 diabetes (T2D). Furthermore, individuals from historically minoritized racial and ethnic groups (e.g. Hispanic/Latinx, African American/Black) are more likely to experience shorter sleep duration compared to adolescents of White/European origin, placing them at even greater risk for disparities in T2D risk.

METHODS

We conducted a literature review on the role of race and ethnicity in adolescent sleep health and its relation to cardiometabolic outcomes, specifically T2D. We use the minority stress model and the stress and coping theory as guiding theoretical frameworks to examine individual and societal level factors that may contribute to sleep health disparities and their downstream effects on T2D risk.

RESULTS

This review highlights that the unique race-related stressors adolescents from minoritized groups face may play a role in the sleep and T2D connection on a biological, psychological, and social level. However, although there has been advancement in the current research on adolescent racial and ethnic sleep health disparities in relation to T2D, mechanisms underlying these disparities in sleep health need further investigation. Addressing these gaps is crucial for identifying and mitigating sleep health disparities and T2D among racial and ethnic minority youth.

CONCLUSION

We conclude with a discussion of the implications and future research directions of racial and ethnic disparities in sleep health and T2D prevention research. A comprehensive understanding of adolescent sleep health disparities has potential to better inform preventative and educational programs, interventions, and policies that promote sleep health equity and improve cardiometabolic outcomes like T2D.

A Person-Based Web-Based Sleep Intervention Aimed at Adolescents (SleepWise): Randomized Controlled Feasibility Study

BACKGROUND

Adolescents are advised to sleep 8-10 hours per night; however, most do not sleep for this recommended amount. Poor adolescent sleep is associated with detrimental health outcomes, including reduced physical activity, risk-taking behaviors, and increased depression and anxiety levels, making this an important public health concern. Existing interventions targeting adolescent sleep are often unsuccessful or their effectiveness unclear, as they are frequently noninteractive, time-consuming, and lack a strong theoretical foundation; highlighting an urgent need for innovative interventions deemed acceptable by adolescents.

OBJECTIVE

The main objective of this study was to determine the acceptability, feasibility, and preliminary impact of a web-based person-based sleep intervention (SleepWise) on adolescent sleep quality. Participant incentivization was also explored to understand its impact on engagement, acceptability, and sleep quality.

METHODS

A feasibility trial was conducted to test the feasibility, acceptability, and preliminary impact of SleepWise on adolescent sleep quality, developed based on the person-based approach to intervention development. In total, 90 participants (aged 13-17 years) from further education institutions and secondary schools were recruited for two 2-arm randomized controlled trials. One trial (trial 1) was incentivized to understand the impact of incentivization. Acceptability and sleep quality were assessed via questionnaires, and a mixed methods process evaluation was undertaken to assess participant engagement and experience with SleepWise. Engagement was automatically tracked by SleepWise, which collected data on the date and time, pages viewed, and the number of goals and sleep logs completed per participant. Semistructured interviews were carried out to gain participant feedback.

RESULTS

Participants in both trials reported high levels of acceptability (trial 1: mean 21.00, SD 2.74; trial 2: mean 20.82, SD 2.48) and demonstrated similar levels of engagement with SleepWise. Participants in trial 1 viewed slightly more pages of the intervention, and those in trial 2 achieved their set goals more frequently. Improvements in sleep quality were found in both trials 1 and 2, with medium (trial 1) and large (trial 2) effect sizes. A larger effect size for improvement in sleep quality was found in the nonincentivized trial (d=0.87), suggesting that incentivization may not impact engagement or sleep quality. Both trials achieved acceptable recruitment (trial 1, N=48; trial 2, N=42), and retention at 5 weeks (trial 1: N=30; trial 2: N=30). Qualitative findings showed that adolescents lead busy lifestyles, which may hinder engagement; however, participants deemed SleepWise acceptable in length and content, and made attempts at behavior change.

CONCLUSIONS

SleepWise is an acceptable and potentially efficacious web-based sleep intervention aimed at adolescents. Findings from this study showed that incentivization did not greatly impact engagement, acceptability, or sleep quality. Subject to a full trial, SleepWise has the potential to address the urgent need for innovative, personalized, and acceptable sleep interventions for adolescents.

TRIAL REGISTRATION

OSF Registries osf.io/yanb2; https://osf.io/yanb2.

Sleep Hygiene Intervention Improves Sleep Time and Duration in High School Students

Objective  To evaluate the effects of a sleep hygiene education program for adolescents to address excessive daytime sleepiness, insomnia, and sleep-related behaviors. Materials and Methods  The participants were 98 high school students from the 11th and 12th grades. A day-long health promotion action was conducted at their school science fair to disseminate relevant information about sleep disorders. Social status and sleep perception and habits were evaluated through the following validated questionnaires: the Brazilian Economic Classification Criteria, a questionnaire on sleep habits for adolescents, the Pediatric Daytime Sleepiness Scale, the Insomnia Severity Index, and the Sleep Time-Related Information and Communication Technology questionnaire. The questionnaires were administered before the fair and 12 months after participation, and the results before and after the intervention were compared by means of the Student t -test and the Fisher exact test. For the correlations involving the results, the Pearson correlation was used with the level of significance of p  < 0.05. Results  A qualitative reduction in poor bedtime habits was observed after the intervention, such as watching television and leaving a cell phone on with sound. A higher frequency of use of electronic devices can affect school performance and contribute to later bedtime on weekends ( p  < 0.001). Excessive daytime sleepiness was correlated with the excessive use of electronic devices ( p  = 0.017). Conclusion  Some habits changed after the awareness intervention. There was an impact of the use of electronic devices on academic performance, on the regularity of bedtimes, and on excessive daytime sleepiness. We emphasize the importance of health education programs with sustainable actions following actual changes in behavior.

Adolescents' Suggestions on how to Support Their Sleep: A Focus Group Study

Sleeping difficulties among adolescents constitute a pressing public health issue, and it is of the utmost importance that these are approached from a health-promotion perspective. This study explores adolescents' suggestions on how their sleep could be supported. Data were collected via eight focus group interviews with 43 adolescents aged 15-16, in Sweden, and analyzed using qualitative content analysis. The results describe the adolescents' suggestions on how their sleep could be supported in three themes: being supported by involved parents- routines, engagement, and warmth are vital; being supported to achieve knowledge on the "whys" and "hows" of sleep-increased knowledge gives the ability to make well-grounded sleep choices; and being guided into finding balance-balance in life is difficult to achieve and adolescents desire support. Parents, school nurses, health professionals, and anyone who has the opportunity to improve and promote sleep should consider adolescents' suggestions.

Exploring the Impact of Gaming Habits on Sleep Patterns Among Young Adults in Saudi Arabia: A Cross-Sectional Study

Background Video gaming is increasingly popular among young adults, potentially affecting health and daily routines, especially sleep patterns. In Al-Ahsa, Saudi Arabia, the impact of video gaming on sleep and health among young adults is not well understood. This study aims to explore this relationship, focusing on how video gaming habits influence sleep patterns and associated health outcomes. Methods This cross-sectional survey utilized an adapted online questionnaire to gather data on demographics, video gaming habits, sleep patterns, and body mass index from young adults in Al-Ahsa. Statistical analysis, including descriptive statistics, chi-square tests, and multivariable logistic regression, was applied to examine the associations between video gaming habits and sleep sufficiency. Results The study included 302 participants, including 165 (54.6%) females. A majority reported playing video games for less than one hour daily (36.1%), with 82.5% preferring online gaming. Notably, 54.3% of participants slept more than six hours nightly, yet challenges with sleep initiation were evident, as 48.0% went to bed past midnight. Multivariable logistic regression highlighted significant factors affecting sleep sufficiency: participants who played games after completing tasks had 80% lower odds of sleep insufficiency compared to those who played before tasks. Overweight participants were found to be 7.7 times more likely to experience sleep insufficiency compared to their underweight peers. Conclusion The study underscores a complex relationship between video gaming habits and sleep patterns among young adults in Al-Ahsa, with significant health implications. It suggests the necessity for interventions promoting balanced gaming habits and improved sleep hygiene to mitigate adverse health outcomes.

Addressing sleep deserts: A proposed call for action

Sleep deserts are a major cause of health inequity. They occur primarily in disadvantaged neighborhoods because of structural racism, social and environmental factors, and dearth of medical services. We describe several strategies that can serve as a feasible action plan to target structural racism, environmental pollution, and impact of climate change. We also suggest ways healthcare providers in these underserved areas can incorporate sleep medicine into their practice. Lastly, we highlight strategies to increase community awareness of sleep health in a culturally sensitive manner. There are several ways, from a policy level to healthcare that we can begin to eliminate sleep deserts, which is urgently needed.

Focus Groups to Inform User-Centered Development of an eHealth Sleep Intervention for Adolescents: Perspectives of Youth with Insomnia Symptoms, with and without Pain

INTRODUCTION

Adolescence is a developmental stage that often coincides with increasing sleep problems. Focus groups were conducted to inform development of an adolescent eHealth sleep intervention by exploring opinions about (1) healthy sleep practices, and (2) using an eHealth intervention.

METHODS

Adolescents 14-18 years old experiencing symptoms of insomnia based on the Insomnia Sleep Index, with and without recurrent pain, and associated stakeholders (i.e., parents, school personnel, and health care providers) were recruited. Across six online focus groups, 24 adolescents with insomnia participated (14 pain-free, 10 with recurrent pain; 10 male, 14 female). Across seven online focus groups, 22 stakeholders participated, including 8 parents, 9 school professionals, and 5 health care providers (10 male, 8 female). Using a content analysis, subthemes were induced from transcripts.

RESULTS

Most healthy sleep practices were perceived as reasonable for adolescents to implement, except avoiding technology before bed and using bedrooms only for sleep. Three primary barriers to sleep practices were identified, including a variable schedule due to lifestyle factors, technology at night, and academics interfering with sleep, and only in the pain group, the barrier related to pain was identified. Content addressing adolescent-specific barriers was considered important to include in a sleep intervention. Desirable eHealth components included interactive features, videos, audio, and pictures to present information. A common barrier to using an eHealth sleep intervention was the program feeling too academic, with accessibility of the sleep information and strategies as a common facilitator.

CONCLUSIONS

This research represents the first step in a user-centered approach to developing an adolescent eHealth sleep intervention. These results provide insights from a range of perspectives on guiding adolescents to follow healthy sleep practices. Next, these findings will be integrated in the development of an eHealth intervention for adolescents with and without recurrent pain.

Pediatric sleep: current knowledge, gaps, and opportunities for the future

This White Paper addresses the current gaps in knowledge, as well as opportunities for future studies in pediatric sleep. The Sleep Research Society's Pipeline Development Committee assembled a panel of experts tasked to provide information to those interested in learning more about the field of pediatric sleep, including trainees. We cover the scope of pediatric sleep, including epidemiological studies and the development of sleep and circadian rhythms in early childhood and adolescence. Additionally, we discuss current knowledge of insufficient sleep and circadian disruption, addressing the neuropsychological impact (affective functioning) and cardiometabolic consequences. A significant portion of this White Paper explores pediatric sleep disorders (including circadian rhythm disorders, insomnia, restless leg and periodic limb movement disorder, narcolepsy, and sleep apnea), as well as sleep and neurodevelopment disorders (e.g. autism and attention deficit hyperactivity disorder). Finally, we end with a discussion on sleep and public health policy. Although we have made strides in our knowledge of pediatric sleep, it is imperative that we address the gaps to the best of our knowledge and the pitfalls of our methodologies. For example, more work needs to be done to assess pediatric sleep using objective methodologies (i.e. actigraphy and polysomnography), to explore sleep disparities, to improve accessibility to evidence-based treatments, and to identify potential risks and protective markers of disorders in children. Expanding trainee exposure to pediatric sleep and elucidating future directions for study will significantly improve the future of the field.

Partnerships at the Interface of Education and Mental Health Services: The Utilisation and Acceptability of the Provision of Specialist Liaison and Teacher Skills Training

Partnerships between school staff and mental health professionals have the potential to improve access to mental health support for students, but uncertainty remains regarding whether and how they work in practice. We report on two pilot projects aimed at understanding the implementation drivers of tailored strategies for supporting and engaging front-line school staff in student mental health. The first project provided regular, accessible mental health professionals with whom school staff could meet and discuss individual or systemic mental health concerns (a school 'InReach' service), and the other offered a short skills training programme on commonly used psychotherapeutic techniques (the School Mental Health Toolbox; SMHT). The findings from the activity of 15 InReach workers over 3 years and 105 individuals who attended the SMHT training demonstrate that school staff made good use of these services. The InReach workers reported more than 1200 activities in schools (notably in providing specialist advice and support, especially for anxiety and emotional difficulties), whilst most SMHT training attendees reported the utilisation of the tools (in particular, supporting better sleep and relaxation techniques). The measures of acceptability and the possible impacts of the two services were also positive. These pilot studies suggest that investment into partnerships at the interface of education and mental health services can improve the availability of mental health support to students.

Healthy sleep for healthy schools: A pilot study of a sleep education resource to improve adolescent sleep

ISSUE ADDRESSED

Insufficient sleep and unhealthy sleep practices in adolescents are associated with significant health risks. Sleep education programs in schools aim to improve sleep behaviour. A new eLearning sleep education program, Healthy Sleep for Healthy Schools (HS4HS), was developed focused on these goals and is distinguishable from other sleep education programs because it is delivered by teachers, making it more sustainable and adaptable for schools. We aimed to evaluate if HS4HS would improve student sleep knowledge, healthy sleep practices, sleep duration and reduce sleepiness. We also aimed to understand if this intervention could be successfully implemented by trained teachers.

METHODS

Teachers trained in sleep delivered HS4HS to 64 South Australian students in year 9 (aged 13-14 years) over 6 weeks during regular school curriculum. A sleep education survey assessing sleep patterns (such as healthy sleep practices, time in bed and sleepiness), and a sleep knowledge questionnaire was completed pre- and post-HS4HS delivery. Evaluations were also completed by teachers.

RESULTS

Sleep knowledge and healthy sleep practices significantly improved post intervention. Time in bed on both school days and weekends increased slightly and sleepiness decreased slightly, but these changes were not statistically significant. Teachers found the program useful, comprehensive and easy to incorporate into their curricula.

CONCLUSIONS

After short training, teachers can deliver sleep education during class and improve sleep practices in their students. This suggests that this program may offer potential as an effective and useful resource for teachers wanting to include sleep health in their curriculum. SO WHAT?: Sleep is the foundation of good health and teachers can promote and integrate sleep education into their curricula for the first time with this online teacher focussed program, which has the potential to be a sustainable sleep health promotion resource.

Effect Evaluation of a School-Based Intervention Promoting Sleep in Adolescents: A Cluster-Randomized Controlled Trial

BACKGROUND

This study evaluated the effect of the school-based intervention Charge Your Brainzzz on adolescents' social-cognitive determinants, sleep hygiene and sleep duration and quality.

METHODS

A cluster-randomized controlled trial was conducted with 972 students from 10 Dutch high schools. Schools were randomly allocated to the intervention (N = 5) or control condition (N = 5). Outcomes were measured with the digital Consensus Sleep Diary and via a digital questionnaire, based on valid measures. Data were collected at baseline (T0), ±1.5 weeks post-intervention (T1) and ±3 months post-intervention (T2). Mixed model analyses were performed to estimate the effects on social-cognitive determinants, sleep hygiene, and sleep outcomes.

RESULTS

The intervention increased sleep knowledge post-intervention (b = 1.91; 95%CI: 1.22-2.60) and at follow up (b = 1.40; 95%CI: 0.70-2.10). The intervention was also effective in changing adolescents' attitudes (b = 0.10; 95%CI: 0.01-0.19) and perceived behavioral control (b = 0.11; 95%CI: 0.01-0.22) post-intervention. No positive changes were found regarding subjective norms, behavioral intentions, sleep hygiene, or sleep outcomes.

CONCLUSIONS

The intervention improved adolescents' sleep knowledge, attitude, and perceived behavioral control. To significantly impact sleep health, theoretically sound and systematically developed interventions are needed which take into account the interplay between sleep, sleep-related behaviors, and adolescents' social and physical environment.

CLINICAL TRIAL REGISTRATION

Trial name: Evaluation of the school-based intervention Charge Your Brainzzz promoting sleep in adolescents; URL: https://doi.org/10.1186/ISRCTN36701918; ID: ISRCTN36701918.

Sleep in an At Risk Adolescent Group: A Qualitative Exploration of the Perspectives, Experiences and Needs of Youth Who Have Been Excluded From Mainstream Education

The sleep needs, experiences and viewpoints were explored for UK adolescents who have been excluded from mainstream education. Qualitative data was gathered through interviews with 9 participants, aged 11-15 years, who also completed questionnaires. The participants had symptoms of inadequate sleep, poor sleep hygiene behaviours and were not getting the recommended amount of sleep on school nights. Participants described sleep patterns involving often staying up late and having different sleep timing on weekends than weekdays and having difficulties with their sleep. Use of technology and the relevance of family were identified as important and associated with facilitating and hindering factors for sleep. Participants communicated that they lack control over aspects of their sleep and their lives. The experiences and views of the participants can inform professionals' understanding of how to collaborate with adolescents to improve their sleep and highlight that continued development of sleep education programmes is timely.

Sleep is essential to health: an American Academy of Sleep Medicine position statement

CITATION

Sleep is a biological necessity, and insufficient sleep and untreated sleep disorders are detrimental for health, well-being, and public safety. Healthy People 2030 includes several sleep-related objectives with the goal to improve health, productivity, well-being, quality of life, and safety by helping people get enough sleep. In addition to adequate sleep duration, healthy sleep requires good quality, appropriate timing, regularity, and the absence of sleep disorders. It is the position of the American Academy of Sleep Medicine (AASM) that sleep is essential to health. There is a significant need for greater emphasis on sleep health in education, clinical practice, inpatient and long-term care, public health promotion, and the workplace. More sleep and circadian research is needed to further elucidate the importance of sleep for public health and the contributions of insufficient sleep to health disparities.

CITATION

Ramar K, Malhotra RK, Carden KA, et al. Sleep is essential to health: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2021;17(10):2115-2119.

Impact of an Online Sleep and Circadian Education Program on University Students' Sleep Knowledge, Attitudes, and Behaviours

University students consistently report poor sleep. We conducted a before-and-after study to evaluate the impact of an online 10-week course on undergraduate students' sleep knowledge, attitudes, and behaviours at 6-month follow-up. Data were collected via baseline course surveys (August-September 2020) and follow-up surveys distributed via email (February-March 2021). n = 212 students completed baseline surveys and n = 75 (35%) completed follow-up. Students retained to follow-up possessed higher baseline sleep knowledge and received higher course grades. At the 6-month follow-up, sleep knowledge had increased (mean score out of 5: 3.0 vs. 4.2, p < 0.001). At baseline, 85% of students aimed to increase their sleep knowledge and 83% aimed to improve their sleep. At follow-up, 91% reported being more knowledgeable and 37% reported improved sleep. A novel Stages of Change item revealed that 53% of students' attitudes towards their sleep behaviours had changed from baseline. There was a reduction in sleep latency at follow-up (mean 33.3 vs. 25.6 min, p = 0.015), but no change in the total Pittsburgh Sleep Quality Index score. In summary, completion of an online course led to increased sleep and circadian knowledge and changed sleep attitudes, with no meaningful change in sleep behaviours. Future interventions should consider components of behavioural change that go beyond the knowledge-attitudes-behaviour continuum.

Engineering a mobile platform to promote sleep in the pediatric primary care setting

Study Objectives

Pediatricians lack tools to support families at home for the promotion of childhood sleep. We are using the Multiphase Optimization Strategy (MOST) framework to guide the development of a mobile health platform for childhood sleep promotion. The objective of this study is to demonstrate feasibility of a mobile health platform towards treating children with insufficient sleep.

Methods

Children aged 10–12 years were enrolled (Study #1: N = 30; Study #2: N = 43). Participants wore a sleep tracker to measure sleep duration. Data were retrieved by a mobile health platform, programmed to send introductory messages during run-in (2 weeks) and goal achievement messages during intervention (7 weeks) periods. In study #1, participants were randomized to control, gain-framed incentive or loss-framed incentive arms. In study #2, participants were randomized to control, loss-framed incentive, normative feedback or loss-framed incentive plus normative feedback arms.

Results

In study #1, 1514 nights of data were captured (69%) and sleep duration during the intervention was higher by an average of 21 (95% CI: −8, 51) and 34 (95% CI: 7, 61) minutes per night for the gain-framed and loss-framed arms, respectively, compared to controls. In study #2, 2,689 nights of data were captured (81%), with no major differences in average sleep duration between the control and the loss-framed or normative feedback arms.

Conclusions

We have developed and deployed a mobile health platform that can capture sleep data and remotely communicate with families. Promising candidate intervention components will be further investigated under the optimization phase of the MOST framework.

Clinical Trials

Both studies included in this manuscript were registered at clinicaltrials.gov:

-Study #1: NCT03263338

-Study #2: NCT03426644

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.

Lessons Learned in Conducting Community Participatory School-Based Health Research on an American Indian Reservation

BACKGROUND

Describing lessons learned from using a community-based participatory research (CBPR) approach to conduct school-based child health research in a tribal community is an important contribution to the literature.

OBJECTIVES

To identify how CBPR principles shaped the process of conducting a school-based child health intervention, and to describe lessons learned.

METHODS

The study evaluates how CBPR principles guided a mixed-methods, school-based child health intervention to increase physical activity (PA).

RESULTS

Nine key lessons are identified, associated with CBPR principles.

CONCLUSIONS

This information can help researchers understand how to successfully navigate the challenges and opportunities of conducting CBPR-guided research in the context of a small, short-term project, including leadership turnover, multiple Institutional Review Board (IRB)s, and study design approaches amidst schools policy changes. Collectively, understanding the lessons learned through the perspective of CBPR principles may help others conduct meaningful research with schools and children in tribal communities.

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.

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

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

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Programme effectiveness was evaluated using questionnaires and actigraphy.

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

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

Modifiable parental factors in adolescent sleep: A systematic review and meta-analysis

Sleep problems are prevalent during adolescence, but parents may be able to support adolescents to sleep better. A systematic search of records from six databases from inception up to November 2019, identified 103 peer-reviewed publications that examined behaviourally and cognitively modifiable parental factors associated with sleep in adolescents aged 12-18 years. Although included studies were largely cross-sectional and heterogeneous, with heavy reliance on self-reported measures, associations with sound, convergent levels of evidence were found for: 1) parental rule-setting for bedtimes and parent sleep behaviours with longer sleep duration in adolescents; 2) healthy parent sleep and family functioning with better adolescent sleep quality; and 3) parental warmth with better adolescent daytime functioning. Effect sizes were in the small to moderate range. The identified parental factors are recommended targets for inclusion in parenting programs to support adolescent sleep, however, would require validation in intervention studies. Opportunities for research are outlined for the identified parental factors, sleep domains with limited evidence, and better understanding the mechanisms or possible moderators in the associations between parental factors and sleep outcomes.

Engineering a Mobile Platform to Promote Sleep in the Pediatric Primary Care Setting

Background

Pediatricians lack tools to support families at home for the promotion of childhood sleep. We are using the Multiphase Optimization Strategy (MOST) framework to guide the development of a mobile health platform for childhood sleep promotion.

Purpose

Under the preparation phase of the MOST framework, to demonstrate feasibility of a mobile health platform towards treating children with insufficient sleep.

Methods

Children aged 10-12y were enrolled (Study #1: N=30; Study #2: N=43). Participants wore a sleep tracker to measure sleep duration. Data were retrieved by a mobile health platform, programmed to send introductory messages during run-in (2 weeks) and goal achievement messages during intervention (7 weeks) periods. In study #1, participants were randomized to control, gain-framed incentive or loss-framed incentive arms. In study #2, participants were randomized to control, loss-framed incentive, normative feedback or loss-framed incentive plus normative feedback arms.

Results

In study #1, 1,514 nights of data were captured (69%) and sleep duration during the intervention was higher by an average of 21 (95% CI: -8, 51) and 34 (95% CI: 7, 61) minutes per night for the gain-framed and loss-framed arms, respectively, compared to controls. In study #2, 2,689 nights of data were captured (81%), with no major differences in average sleep duration between the control and the loss-framed or normative feedback arms.

Conclusion

We have developed and deployed a mobile health platform that can capture sleep data and remotely communicate with families. Promising candidate intervention components will be further investigated under the optimization phase of the MOST framework.

Leveraging Technology to Improve Health in Adolescence: A Developmental Science Perspective

As technologies continue to evolve at exponential rates, online platforms are becoming an increasingly salient social context for adolescents. Adolescents are often early adopters, savvy users, and innovators of technology use. This not only creates new vulnerabilities but also presents new opportunities for positive impact-particularly, the use of technology to promote healthy learning and adaptation during developmental windows of opportunity. For example, early adolescence appears to represent a developmental inflection point in health trajectories and in technology use in ways that may be strategically targeted for prevention and intervention. The field of adolescent health can capitalize on technology use during developmental windows of opportunity to promote well-being and behavior change in the following ways: (1) through a deeper understanding of the specific ways that developmental changes create new opportunities for motivation and engagement with technologies; (2) by leveraging these insights for more effective use of technology in intervention and prevention efforts; and (3) by combining developmental science-informed targeting with broader-reach technologic approaches to health behavior change at the population level (e.g., leveraging and changing social norms). Collaboration across disciplines-including developmental science, medicine, psychology, public health, and computer science-can create compelling innovations to use digital technology to promote health in adolescents.

Do different factors predict the adoption and maintenance of healthy sleep behaviors? A reasoned action approach

Sleep deprivation is a serious public health concern in the United States that often goes unnoticed, particularly among college students and young adults. Concerted efforts are needed to help those who are not engaging in healthy sleep behaviors, while also helping those who are already maintaining healthy sleep behaviors. The purpose of the study was to evaluate theory-based determinants of intentions toward healthy sleep behaviors among students currently not sleeping 7-9 hr per night, oriented toward initiating the behavior (to start sleeping 7-9 hr per night in the next 30 days; behavioral adoption), and students currently sleeping 7-9 hr per night, oriented toward maintaining the behavior (sleeping 7-9 hr per night for the next 6 months; behavioral maintenance). The theoretical framework for this study was the reasoned action approach (RAA). A valid and reliable survey was distributed online to university students (adopters = 310, maintainers = 300). Regression analyses revealed which latent constructs predicted variance of intentions, using a three-construct and a six-construct model. For the adoption group, attitudes, perceived norms, and perceived behavioral control (PBC) accounted for 29.3% of the variance of intentions, and perceived norms and PBC accounted for 32.6% of the variance of intentions for the maintenance group. Furthermore, PBC, stemming from capacity (self-efficacy), was found to have the strongest influence on intentions for both groups. Results from this study support the use of the RAA as a model for designing future sleep interventions. Implications and recommendations for future research and practice are presented.

Sleep Timing During Adolescence: A Latent Transition Analysis Approach

Objective/Background: This paper utilized a person-centered approach to examine individual differences in sleep timing cross-sectionally and prospectively in adolescents. Participants: Data from Waves 5 and 6 of the Longitudinal Study of Australian Children were used. At Wave 5, the sample included 3,552 Australian adolescents aged 12-13 years (51% males, 49% females); 84% provided data at two-year follow-up (Wave 6). Methods: Through structured interviews, adolescents provided information on sleep timing (bedtimes, sleep-onset times, and wake times) on weekends and weekdays, and relevant covariates. Latent profile analysis identified sleep profiles at Waves 5 and 6 separately; latent transition analysis examined stability and change in profiles across time. Results: Six sleep timing profiles were identified at age 12-13 years: Early Larks (n = 228; 6.4%); Larks (n = 1257; 35.4%); Intermediate (n = 1311; 36.9%); Owls (n = 351; 9.9%); Variable Owls (n = 308; 8.7%); and, Late Owls (n = 97; 2.7%). Six similar profiles were identified at age 14-15 years. The latent transition analysis indicated that the Early Larks, Larks, and Intermediate profiles were more stable over time compared with the Owls, Variable Owls, and Late Owls profiles. Higher body mass index (BMI) and longer screen time predicted transitions from Larks and Early Larks to the Owls, Variable Owls, and Late Owls profiles. Conclusions: Many adolescents showed healthy sleep timing, which continued with age. However, the Variable Owls, Owls, and Late Owls profiles reflected less healthy and more variable sleep patterns that may require targeted interventions.

Application of health behaviour theory to sleep health improvement

Although sleep hygiene is often used for broad sleep health promotion efforts, sleep hygiene education programmes are largely ineffective. These programmes are limited by their lack of a theoretical foundation. Health behaviour theory (HBT) has been used for decades to successfully predict and modify many health behaviours, but its use in the study of sleep health is rare. The purpose of this review is threefold. First, four dominant HBTs will be introduced. Second, the brief literature on HBT and sleep health will be reviewed. Lastly, a translational research agenda will be proposed. The present review concludes that HBT shows potential in both the prediction and modification of sleep health, and that there are several short- and long- term research goals to advance these efforts.

Preventing sleep deficit in adolescents: Long-term effects of a quasi-experimental school-based intervention study

Adolescents are at risk of sleep deficit, which has serious consequences for their daytime functioning. However, school‐based interventions to improve sleep have shown limited success. This might be due to the content of the programmes (e.g., not targeting central factors such as daytime stress and technology use) or because changes have not been captured due to a lack of long‐term follow‐ups. Hence, the aim of this study was to evaluate the long‐term effects of a school‐based sleep education curriculum including time‐management training. The study used a quasi‐experimental design. Participants were 3,622 adolescents (mean age 13.7, 48% girls); 286 were in the intervention group and 3,336 were followed as a natural control group. Data were collected before the intervention and at a 1‐year follow‐up. We divided participants into three groups according to baseline sleep duration (calculated from self‐reported bed‐ and wake times, minus sleep onset latency): insufficient (<7 hr), borderline (7–8 hr) and adequate (>8 hr). Adolescents in the intervention group were ~2 times less likely to report insufficient sleep at follow‐up as compared to controls. Sleep knowledge improved significantly in the intervention group but there were no changes in emotional sleep hygiene (e.g., bedtime worry) and perceived stress. Surprisingly, technology use increased and behavioural sleep hygiene worsened in the intervention group. Although the mechanisms of change need further investigation, the results of this study point to potential long‐term benefits of school‐based sleep programmes.

Sleep education in primary school prevents future school refusal behavior

BACKGROUND

Sleep disorders, along with extreme difficulty in awakening, are one of the main causes of school refusal. The accumulation of chronic sleep deprivation accompanied by a late-night lifestyle is considered the basic inciting factor.

METHODS

From 2007, we initiated a sleep education program (Min-Iku) in Fukui, Japan, with the aim of improving pupil lifestyle and preventing future school refusal. All grade 1-6 Miyake-primary school (M-PS) pupils participated in this program and gave their informed consent. The Min-Iku included (i) implementation of a "daily life rhythm survey" by recording the sleep-wake rhythm in a table for 14 days; (ii) evaluation of the sleep table according to the classifications A-D; (iii) interviews of stage D children and their guardians; (iv) lectures on the importance of daily life rhythms for parents and teachers; and (v) 45 min classwork for all participating pupils.

RESULTS

In 2007, 10% of M-PS graduates developed school refusal behavior after entering Kaminaka junior high school (K-JHS). The incidence of school refusal, however, decreased each year after the implementation of the Min-Iku program and finally reached 0 by 2012. The sleep onset time of pupils improved each year, with the most common sleep time reaching 9:30 p.m. on both weekdays and holidays. With an earlier sleep time, the night-time sleep duration was significantly extended (P < 0.001 vs 2007 data).

CONCLUSION

The Min-Iku program for primary school pupils successfully achieved a more routine night-time sleep pattern and a regular life rhythm, which prevented school refusal during the subsequent JHS years.

A Qualitative Assessment of the Acceptability of Smartphone Applications for Improving Sleep Behaviors in Low-Income and Minority Adolescents

Background: Daily behaviors such as sleep can be targeted by smartphone app-based interventions, with potential utility among young people of minority ethnic backgrounds who commonly access smartphone devices and are short sleepers. There is a need to understand the acceptability and youth's readiness to use apps to improve sleep, and to identify desired app components that would motivate engagement. Participants and Methods: We conducted three focus group discussions (N = 27 total, age 14-18 years) within low- and middle-income ethnically diverse Boston neighborhoods. We also interviewed 10 participants who provided specific feedback on two commercially available sleep-promoting apps, one of which they had used on their smartphone preceding the interviews. All focus group discussions and interviews were audio-recorded, transcribed, and thematically analyzed. Results: We identified several barriers to adoption of sleep hygiene interventions, namely reluctance to follow scheduled sleep routines on weekends and concern about "parting" with electronics at bedtime. Participants were intrigued by the idea of adopting an app-based sleep intervention, but were skeptical that they could successfully adopt sleep hygiene practices, and were more interested in making changes on school days than on weekends. Nonetheless, the overall feedback on two commercial sleep apps, neither targeted at youth, was positive, with a good adherence and engagement rate, and perceived health benefits. Conclusions: Our findings highlight the need to adapt sleep hygiene recommendations to targeted populations, considering preferences and social and cultural contextual factors. Our research also underscores the importance of the platform, setting, and messenger when delivering health information to adolescents.

Challenges in implementing and assessing outcomes of school start time change in the UK: experience of the Oxford Teensleep study

OBJECTIVE

Later school start times for adolescents have been implemented in the US and associated benefits found, although no randomised controlled trials (RCT) have been undertaken. The objective of this study was to evaluate the impact of two school interventions in the UK, a delayed start time and a sleep education programme, on students' academic performance, sleep outcomes and health-related quality of life.

METHODS

The study had an RCT design to enable an investigation into the differential effects of two interventions or a combination of both: schools were to delay their start time to 10:00am and/or provide a classroom-based sleep education programme. The recruitment target was 100 state (non-fee-paying) secondary schools. Participants were to be students in Year 10/11 (14-16-year-olds).

RESULTS

Despite much media coverage, only two schools volunteered to take part in the RCT. The main challenges faced in recruitment fell under three categories: research design, school, and project-specific issues. The delayed start time and prospect of randomisation to this intervention were the overwhelming reasons cited for not taking part. Facilitators and barriers to research were identified. Recommendations include carrying out a feasibility study prior to a main trial, allowing adequate time for recruitment, involving stakeholders throughout the decision-making process, incorporating independent (fee-paying) schools in recruitment, focusing on students not taking important examinations or involving an older year group with greater independence.

CONCLUSION

The Teensleep study provides supporting evidence that evaluating the effects of a change in school start times through an RCT is unfeasible in the UK.

[Insomnia and Hypersomnia among Children and Adolescents with Psychiatric Disorders]

Insomnia and Hypersomnia among Children and Adolescents with Psychiatric Disorders The common symptom of sleep disorders is non-restorative sleep, which results in daytime sleepiness. Therefore in clinical practice simultaneous complaints of "not enough" and "too much" sleep are very frequent. For the investigation and treatment of organic sleep disorders, available instruments, guidelines and specialised institutions (sleep centres or sleep laboratories) are more advanced than for non-organic sleep disorders. Especially in the child and adolescent psychiatric and psychotherapeutic field this complicates an appropriate treatment. In addition multiple psychiatric, neurological and other somatic diseases can disrupt nighttime sleep and cause impairments during the day too. There are various instruments and methods to cover disturbed nocturnal sleep, some of which have already found widespread use in clinical practice (e. g. sleep diaries or specific questionnaires and interviews). For the examination of daytime sleepiness instruments and methods are available too, which by now seem to be less widely used. Against this background an overview of definitions, distinctive features and clinical instruments as well as guidelines for dealing with "too much and too little sleep" during the day or at night shall be presented.

Evaluating Accessible Sleep Health Information in Rural and Urban Contexts: Delivery Face-to-Face or Online?

Objective

New parents need education about infant sleep but is not universally available especially not in regional and rural areas. We delivered sleep education both face-to-face and online to test sleep knowledge acquisition for parents wherever they reside. Best practice delivery of accessible sleep health information for new families needs to be investigated more carefully in order for specialist services to be universally available.

Methods

Pre- and post-information session questionnaires (n = 32) assessed levels of knowledge acquisition and comparisons tested differences between face-to-face seminars compared with an online webinar.

Results

Sleep knowledge across participants was low (69% scoring < 50%). Sleep knowledge significantly increased for both the webinar delivery group (P = .002) and face-to-face delivery group (P = .001). No significant differences in knowledge acquisition were found between face-to-face vs online delivery (P = .170), suggesting both modes of delivery were sufficient to improve parental sleep knowledge.

Conclusions

Parental sleep knowledge, while low, increased with education. Online delivery was similar to face-to-face delivery suggesting ease of access for rural and remote communities needing specialist sleep information.

Implications for public health

Information delivered online is effective and offers a health delivery solution to regional and remote parents unable to access sleep services and rendering sleep service accessibility more equitable.

"Let's talk about sleep": a qualitative examination of levers for promoting healthy sleep among sleep-deprived vulnerable adolescents

OBJECTIVE

Deficient sleep is highly prevalent in disadvantaged adolescents and contributes to a range of adverse health and behavioral outcomes. We examined mediating mechanisms and strategies that adolescents adopt to improve sleep, and possible levers for promoting sleep in this population.

METHODS

We conducted three focus groups (N = 27 total, age 14-18 years) in adolescents living in low- and middle-income racially/ethnically diverse neighborhoods of Boston, Massachusetts. Participants completed a survey on their sleep and health habits prior to the moderator-led discussions. Discussions were audio-recorded, transcribed, and thematically analyzed.

RESULTS

The study population did not meet the minimum sleep recommendations, and we found a high prevalence of "social jet-lag." We also identified a disconnect between the acknowledgment of the importance of sleep and actual behavior, especially for electronic use. Phone use and screen time were the most commonly cited barriers to a good night's sleep, along with caffeine consumption, which was also high in this sample. There was also a general lack of awareness of sleep hygiene practices and recommendations. Participants reported regulating food intake and physical activity, using allopathic sleep aids, creating a comfortable sleeping environment, and a routine as some strategies to improve sleep.

CONCLUSION

Results from this study suggest facilitating the linkage between participant-generated mediating factors and strategies for better-designed interventions. These include making the negative impact of sleep on health more explicit, improving youth awareness about sleep hygiene, targeting caffeine consumption and electronic use, and introducing sleep recommendations through appropriate and effective channels.

Study Protocol of Sleep Education Tool for Children: Serious Game "Perfect Bedroom: Learn to Sleep Well"

Promoting a healthy sleep is a big challenge and becomes a strategic priority in public health, due to the severe consequences on children's development and risk to psychiatric diseases. Interventions that promote healthy sleep, such as those that focus on the dissemination of behavioral and environmental recommendations of sleep hygiene with children, are presented as an alternative. Serious game design offers wide-reaching domains in health applications and is increasing in popularity, particularly with children and teens because of it's potential to engage and motivate players differently from other interventions. This study aims to evaluate effects of serious game on sleep hygiene recommendations "Perfect Bedroom: learn to sleep well," on sleep habits and sleep parameters of healthy children. This is an experimental, prospective and quantitative study. We will randomize children in experimental (n = 88) and no intervention groups (n = 88). The experiment has four stages (pre-intervention, intervention, post-intervention, and follow-up), which will count with participation of children and their parents/guardians. In the evaluation stages, the guardians will answer questionnaires and scales to assess sociodemographic and health data, sleep habits and sleep pattern of their child. The children themselves will answer the following: a scale to assess sleepiness levels, a questionnaire to evaluate the serious game and the game itself, will characterize their bedroom and the activities they perform before sleep, with strategies developed by researches. Intervention with experimental group conducted with the serious game "Perfect Bedroom" will happen twice a week, for 3 weeks in a row, resulting in six sessions of 50 min each. Inferential analysis will be conducted for comparisons between groups and intragroups to measure effect of intervention in primary outcomes (sleep habits) and secondary outcomes (sleep parameters). We expect that the intervention with this game can provide valuable evidence to a new approach in promoting healthy sleep habits, with applications in clinical, educational, and familiar settings, which could diminish future health issues and risk at psychiatric diseases, decreasing the social burden of treatments for these conditions in children.

Mechanisms underlying the association between insomnia, anxiety, and depression in adolescence: Implications for behavioral sleep interventions

There is robust evidence of an association between insomnia, anxiety, and depression in adolescence. The aim of this review is to describe and synthesize potential mechanisms underlying this association and explore implications for the design of adolescent behavioral sleep interventions. Specifically, we examine whether insomnia symptoms are a mechanism for the development of internalizing symptoms in adolescence and whether sleep interventions are an effective treatment for both insomnia and internalizing symptoms in adolescence because they target the shared mechanisms underlying these disorders. Research using different methodologies points to the role of sequential, parallel, and interacting mechanisms. In this paper, we review a wide range of relevant biological (i.e., polymorphisms and dysregulation in serotonin, dopamine, and circadian clock genes; alterations in corticolimbic and mesolimbic brain circuits; cortisol reactivity to stress; inflammatory cytokine dysregulation; biased memory consolidation; changes in sleep architecture), psychological (i.e., cognitive inflexibility, interpretational biases, judgment biases, negative attribution styles, worry, rumination, biased attention to threat, dysfunctional beliefs and attitudes about sleep, misperception of sleep deficit), and social mechanisms (i.e., reduced and impaired social interactions, unhelpful parenting behaviors, family stress) and propose an integrative multilevel model of how these phenomena may interact to increase vulnerability to both insomnia and internalizing disorders. Several 'biopsychosocial' mechanisms hold promise as viable treatment targets for adolescent behavioral sleep interventions, which may reduce both insomnia and internalizing symptoms.

The Impact of a Randomized Sleep Education Intervention for College Students

STUDY OBJECTIVES

Sleep deprivation can impair attention, mood, and performance; however, few effective sleep education programs are available. The aim of this study was to assess the effect of a sleep education website, Sleep to Stay Awake (sleeptostayawake.org), on sleep behaviors of college students.

METHODS

College students (age 18 years or older) attending a public Midwestern university were randomized to control or intervention groups. All subjects completed baseline surveys that included demographics, Pittsburgh Sleep Quality Index, Patient Health Questionnaire, sleep knowledge, and measures of sleepiness and circadian rhythm. The intervention group then undertook the online intervention. Surveys were repeated at 1 week and at 8 weeks.

RESULTS

Students who participated included 295 controls and 254 intervention subjects. The mean age was 21.9 ± 4.1 years and 41.7% were male. Survey results at 8 weeks showed that more intervention subjects reported improved sleep behaviors (50.3% versus 39.5%, P = .04). Intervention subjects were more likely to stop electronics use earlier (odds ratio [95% confidence interval] = 1.5 [1.0-2.4]), keep a more regular sleep schedule (1.6 [1.06-2.4]), have an earlier weekday rise time (2.4 [1.3-4.4]), and have a lower likelihood of insufficient sleep prior to examinations (0.46 [0.28-0.76]). The intervention group had improvement in mean sleep quality (odds ratio = 5.8 versus 6.6, P < .001) and depression scores (odds ratio = 4.6 versus 5.6, P = .03). No significant differences were found in the other measures.

CONCLUSIONS

A brief and personalized online sleep education intervention improved sleep behaviors, sleep quality, and depressions scores. This novel approach to address sleep deprivation, poor sleep habits, and mood among college students may offer an effective and inexpensive remedy.

Sleep in adolescents and young adults

Sleep has an important role in maintaining health and wellbeing; this relationship is becoming increasingly recognised for adolescents and young adults. Many physicians will encounter young people who present with complaints or conditions that have some relation to poor sleep. This review article looks at why sleep matters within this population group, how it can impact on longer term health consequences and discusses some tools to help enable the clinician to evaluate and address sleep within clinical practice.

Inadequate sleep as a contributor to type 2 diabetes in children and adolescents

Lack of sleep is a modifiable risk factor for adverse health in humans. Short sleep duration and poor sleep quality are common in the pediatric population; the largest decline in sleep duration over the past decades has been seen in children and adolescents. The objective of the present narrative review was to provide for the first time an overview of the literature on sleep and its association with type 2 diabetes mellitus (T2D) biomarkers in children and adolescents. For this narrative review, 23 studies were retained (21 observational and 2 experimental studies). Notwithstanding the conflicting results found in these studies and despite being attenuated by adiposity level, maturity, sex and age, there is still some compelling evidence for an association between sleep duration (for both objective or subjective measurements of duration) and architecture with one or more T2D biomarkers in children and adolescents. The majority of the studies reviewed did focus on sleep duration and one or more T2D biomarkers in children and adolescents, but sleep architecture, more precisely the suppression of slow wave sleep and rapid eye movement sleep, has also been shown to be associated with insulin resistance. Only two studies looked at sleep quality, and the association between sleep quality and insulin resistance was not independent of level of adiposity. Future experimental studies will help to better understand the mechanisms linking insufficient sleep with T2D. Work also needs to be carried out on finding novel and effective strategies aimed at improving sleep hygiene and health outcomes of children and adolescents.

Putting Children's Sleep Problems to Bed: Using Behavior Change Theory to Increase the Success of Children's Sleep Education Programs and Contribute to Healthy Development

Sleep is critical for the healthy development of children, yet most children simply don’t get enough. Whilst school based sleep education programs have been developed for parents and their children, they have had mixed success. We consider how existing school-based sleep education programs can be improved by applying a broader model to behaviour change theory. We find that the mixed success of school-based sleep education programs may be due to a plausible but misleading assumption that simply increasing information about the importance of sleep and the risks of insufficient and/or inefficient sleep, will necessarily result in improved sleep behaviours. We identify the potential benefits of using a more inclusive behavior change theory in the development of sleep education programs with a particular need for theories that incorporate the multiple biological, environmental and social impacts on children’s sleep. Bronfenbrenner’s Bioecological model is presented to illustrate how one such inclusive behavior change theory could significantly improve the success of sleep education programs and ultimately support the healthy development of children.