Improvements of adolescent psychopathology after insomnia treatment: results from a randomized controlled trial over 1 year

Effectiveness of a cognitive-behavioral sleep hygiene intervention for adolescents with ADHD: a randomized controlled trial

OBJECTIVE

Sleep problems are frequent and impairing in adolescents with ADHD. This randomized controlled trial investigates the effectiveness of a newly developed CBT sleep hygiene intervention for adolescents with ADHD - SIESTA.

METHOD

Adolescents with ADHD and sleep problems (N = 92, Mage = 14.36, SD = 1.43, 47% males) were randomized to receive SIESTA next to treatment as usual targeting ADHD (SIESTA+TAU) or TAU only. Adolescent and parent ratings, actigraphy and sleep diaries, were collected at pre-, post-, and at 4 month follow-up test. A linear mixed effects model was used with an intent-to-treat approach.

RESULTS

Results indicated significant improvement in SIESTA+TAU compared to TAU from pre- to post-test on sleep hygiene (effect size =.21), chronic sleep reduction (effect size =.15), and sleep-wake problem behaviors (effect size =.05). Actigraphy and sleep diaries showed no significant differences, with both groups improving on sleep diaries. The improvements in sleep hygiene were maintained at follow-up (effect size =.09). Of secondary outcomes, depressive symptoms reduced significantly more from pre- to post-test in SIESTA+TAU than in TAU only (effect size =.09).

CONCLUSIONS

This study indicates that SIESTA is effective at improving sleep hygiene, perceived sleep problems, and depressive symptoms in adolescents with ADHD. However, to maintain long-term effects, booster sessions may be beneficial.

Depression in High-Risk Offspring: The Mediating Role of Sleep Problems

Parental depression is associated with offspring depression and sleep problems are prospectively associated with the development of depression. However, little work has examined sleep problems in the offspring of depressed parents and whether these problems partially account for the association between parent and offspring depression. This longitudinal study examined the indirect effect of sleep problems on the association between parent psychopathology and offspring depression in a sample of 10,953 10 to 12-year-old children participating in the Adolescent Brain and Cognitive Development (ABCD) study. Controlling for age, sex, and other forms of parent psychopathology, we found significant indirect effects of parent to offspring depression through parent and youth reports of youth insomnia and hypersomnia. We also found indirect effects of parent history of anxiety and drug use problems to offspring depression through insomnia, and indirect effects of parent history of anxiety, drug use problems, and alcohol use problems to offspring depression through hypersomnia. Our findings show that sleep may be a mechanism of the transmission of parent depression, anxiety, drug use problems, and alcohol use problems to offspring depression. Mitigating sleep problems represents a potential avenue for preventative interventions in youth with a heightened susceptibility to depression.

Effectiveness of app-based cognitive behavioral therapy for insomnia on preventing major depressive disorder in youth with insomnia and subclinical depression: A randomized clinical trial

BACKGROUND

Increasing evidence suggests that insomnia plays an important role in the development of depression, supporting insomnia intervention as a promising approach to prevent depression in youth. This randomized controlled trial evaluated the effectiveness of app-based cognitive behavioral therapy for insomnia (CBT-I) in preventing future onset of major depressive disorder (MDD) in youth.

METHODS AND FINDINGS

This was a randomized, assessor-blind, parallel group-controlled trial in Chinese youth (aged 15-25 years) with insomnia disorder and subclinical depressive symptoms. Participants were randomly assigned (1:1) to 6-week app-based CBT-I or 6-week app-based health education (HE) delivered through smartphones. Online assessments and telephone clinical interviews were conducted at baseline, post-intervention, 6- and 12-month follow-ups. The primary outcome was time to onset of MDD. The secondary outcomes included depressive symptoms and insomnia at both symptom and disorder levels. Between September 9, 2019, and November 25, 2022, 708 participants (407 females [57%]; mean age, 22.1 years [SD = 1.9]) were randomly allocated to app-based CBT-I group (n = 354) or app-based HE group (n = 354). Thirty-seven participants (10%) in the intervention group and 62 participants (18%) in the control group developed new-onset MDD throughout the 12-month follow-up, with a hazard ratio of 0.58 (95% confidence interval 0.38-0.87; p = 0.008). The number needed to treat to prevent MDD at 1 year was 10.9 (6.8-26.6). The app-based CBT-I group has higher remission rates of insomnia disorder than the controls at post-intervention (52% versus 28%; relative risk 1.83 [1.49-2.24]; p < 0.001) and throughout 12-month follow-up. In addition, the CBT-I group reported a greater decrease in depressive (adjusted difference -1.0 [-1.6 to -0.5]; Cohen's d = 0.53; p < 0.001) and insomnia symptoms (-2.0 [-2.7 to -1.3], d = 0.78; p < 0.001) than the controls at post-intervention and throughout 6-month follow-up. Insomnia was a mediator of intervention effects on depression. No adverse events related to the interventions were reported.

CONCLUSIONS

App-based CBT-I is effective in preventing future onset of major depression and improving insomnia outcomes among youth with insomnia and subclinical depression. These findings highlight the importance of targeting insomnia to prevent the onset of MDD and emphasize the need for wider dissemination of digital CBT-I to promote sleep and mental health in the youth population.

TRIAL REGISTRATION

ClinicalTrials.Gov (NCT04069247).

Targeted Sleep Enhancement Reduces Residual Anxiety Symptoms in Peri-Adolescents Previously Treated for Anxiety Disorders

Sleep-related problems (SRPs) are a common precursor to anxiety disorders, especially during peri-adolescence, and may be a predictor of treatment response. However, evidence-based anxiety treatments do not alleviate SRPs to a clinically significant degree. The current study examines whether improving sleep in a sample of young adolescents previously treated for anxiety disorders can further reduce anxiety severity. Participants include 46 adolescents (65% female, ages 9-14 years) previously treated for anxiety disorders who self-selected to participate in a 6-week open trial of targeted sleep enhancement (TIGERS). Measures of parent- and child report on SRPs, and clinician-rated anxiety severity, were collected at several time points of the study: pre-, and postanxiety treatment, pre- and post-TIGERS, and at four yearly follow-ups. Two hierarchical mediation models were run using either parent- or child report on sleep. On the between-subjects level, participants with higher overall average SRPs also had higher overall anxiety severity over all time points. On the within-subjects level, participation in TIGERS was not directly associated with change in anxiety severity-however, participation in TIGERS was associated with a drop in SRPs, which was associated with a drop in anxiety severity. Improving sleep in anxious peri-adolescents further improves anxiety above and beyond anxiety treatment. Further research is needed to confirm the effects of improving sleep on clinical anxiety in a randomized controlled trial.

Cognitive and behavioural therapy for insomnia in the treatment of adolescent insomnia: A systematic review and meta-analysis of randomised controlled trials

Insomnia is common in adolescents with associated negative health consequences. This systematic review and meta-analysis assessed the effect of cognitive behavioural therapy for insomnia interventions on insomnia symptoms and subjective sleep quality in adolescents aged 10-19 years. Key electronic databases, including CINAHL, Embase, MEDLINE, PsycINFO and Scopus, were systematically searched from inception to October 2024, and five randomised controlled trials met inclusion criteria for qualitative synthesis. Four randomised controlled trials, examining a total of 527 participants, were included in the meta-analysis. One randomised controlled trial employing a hybrid cluster design was excluded in quantitative analyses due to the number of clusters and sizes not reported. Cognitive behavioural therapy for insomnia delivered to adolescents with insomnia improved subjective sleep quality and insomnia symptoms, with effect sizes (Hedge's g) of 0.4 and 1.04, respectively. Our findings provide support for the efficacy of cognitive behavioural therapy for insomnia in the treatment of adolescents with insomnia regardless of delivery modality. Further high-quality randomised controlled trials are required to strengthen our findings and understand how best to deliver cognitive behavioural therapy for insomnia to adolescents.

The efficacy of cognitive behavioral therapy for insomnia in adolescents: a systematic review and meta-analysis of randomized controlled trials

Objective

The objective of this systematic review and meta-analysis was to evaluate the overall efficacy of cognitive behavioral therapy for insomnia (CBT-I) in treating insomnia in adolescents, and to examine the efficacy of CBT-I on different sleep-related outcomes in this population.

Methods

Randomized controlled trials (RCTs) of CBT-I on insomnia in adolescents were identified using electronic databases and manual searches. The Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) was used to assess risk of bias in RCTs. A standardized mean difference (SMD) with a 95% confidence interval (CI) was used to combine effect sizes. A sensitivity analysis was performed for each outcome using a stepwise elimination method to assess whether the pooled results were significantly affected by individual studies.

Results

The analysis included 8 RCTs involving a total of 599 participants. The meta-analysis indicated that marked and statistically significant improvements in insomnia (SMD = -1.06; 95% CI -1.65 to -0.47; p < 0.01), sleep onset latency (SMD = -0.99; 95% CI -1.65 to -0.32; p < 0.01), total sleep time (SMD = 0.50; 95% CI 0.10 to 0.90; p = 0.01), and sleep efficiency (SMD = 0.57; 95% CI 0.26 to 0.87; p < 0.01) were observed at post-treatment time point following CBT-I. At follow-up time point, a statistically significant improvement in insomnia (SMD = -0.79; 95% CI -1.42 to -0.17; p = 0.01) was observed following CBT-I.

Conclusion

CBT-I was effective in improving insomnia in adolescents and some sleep-related outcomes, including sleep onset latency, total sleep time, and sleep efficiency. CBT-I was characterized by low risk and high therapeutic benefits and could serve as alternative or adjuvant approaches to medication for the treatment of insomnia. Considering the advantages in terms of safety and efficacy, CBT-I should be the preferred intervention for the treatment of insomnia in adolescents.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, CRD42024526102.

Delivering a sleep intervention across a youth mental health service using non-expert practitioners: A service evaluation

AIMS

Poor sleep is highly prevalent in young people and increases risk of mental health difficulties, yet access to sleep interventions remains limited. This paper evaluates the use of a sleep intervention delivered by non-expert practitioners in a secondary care youth mental health service.

METHOD

Assistant psychologists were trained to deliver a six-session 1:1 cognitive-behavioural sleep intervention adapted for use with young people with mental health difficulties. A within-subject design assessed clinical outcomes relating to sleep (Insomnia Severity Index), psychological distress and personal goals (Goal Based Outcome Measures) at four time points.

RESULTS

High referral, intervention take-up (82.82%) and completion (70%) rates were reported, together with high baseline levels of insomnia (Insomnia Severity Index mean 20.47, SD 3.68) and poor sleep efficiency (56.36%, SD 17.23). Fifty-six young people (average age 19.2 years, SD 3.25) were included in the outcome analysis. Statistically and clinically significant improvements were seen across all outcome measures, with 68% no longer meeting clinical threshold (ISI ≥15) for insomnia at endpoint.

CONCLUSIONS

This study demonstrates exceptionally high levels of clinical need and engagement with a sleep intervention adapted specifically for young people with mental health difficulties. Whilst limited by the uncontrolled design, large improvements in insomnia and psychological distress support its effectiveness and utility in clinical settings. More robust implementation and evaluation is warranted in broader youth mental health services to promote earlier access.

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.

Efficacy of eHealth Versus In-Person Cognitive Behavioral Therapy for Insomnia: Systematic Review and Meta-Analysis of Equivalence

BACKGROUND

Insomnia is a prevalent condition with significant health, societal, and economic impacts. Cognitive behavioral therapy for insomnia (CBTI) is recommended as the first-line treatment. With limited accessibility to in-person-delivered CBTI (ipCBTI), electronically delivered eHealth CBTI (eCBTI), ranging from telephone- and videoconference-delivered interventions to fully automated web-based programs and mobile apps, has emerged as an alternative. However, the relative efficacy of eCBTI compared to ipCBTI has not been conclusively determined.

OBJECTIVE

This study aims to test the comparability of eCBTI and ipCBTI through a systematic review and meta-analysis of equivalence based on randomized controlled trials directly comparing the 2 delivery formats.

METHODS

A comprehensive search across multiple databases was conducted, leading to the identification and analysis of 15 unique randomized head-to-head comparisons of ipCBTI and eCBTI. Data on sleep and nonsleep outcomes were extracted and subjected to both conventional meta-analytical methods and equivalence testing based on predetermined equivalence margins derived from previously suggested minimal important differences. Supplementary Bayesian analyses were conducted to determine the strength of the available evidence.

RESULTS

The meta-analysis included 15 studies with a total of 1083 participants. Conventional comparisons generally favored ipCBTI. However, the effect sizes were small, and the 2 delivery formats were statistically significantly equivalent (P<.05) for most sleep and nonsleep outcomes. Additional within-group analyses showed that both formats led to statistically significant improvements (P<.05) in insomnia severity; sleep quality; and secondary outcomes such as fatigue, anxiety, and depression. Heterogeneity analyses highlighted the role of treatment duration and dropout rates as potential moderators of the differences in treatment efficacy.

CONCLUSIONS

eCBTI and ipCBTI were found to be statistically significantly equivalent for treating insomnia for most examined outcomes, indicating eCBTI as a clinically relevant alternative to ipCBTI. This supports the expansion of eCBTI as a viable option to increase accessibility to effective insomnia treatment. Nonetheless, further research is needed to address the limitations noted, including the high risk of bias in some studies and the potential impact of treatment duration and dropout rates on efficacy.

TRIAL REGISTRATION

PROSPERO CRD42023390811; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=390811.

How do adolescents experience a newly developed Online Single Session Sleep Intervention? A Think-Aloud Study

BACKGROUND

Sleep problems are common in adolescents and have detrimental impacts on physical and mental health and daily functioning. Evidence-based treatment like cognitive behaviour therapy for insomnia (CBT-I) is often hard to access, and adolescents may not engage in and adhere to longer, clinician-delivered interventions. Brief, self-guided, and accessible sleep interventions are needed.

OBJECTIVE

To explore the user experience of a prototype online self-help single session sleep intervention developed for adolescents.

METHODS

Eleven participants aged 17-19 years (8 females, 3 males) took part in online retrospective think-aloud interviews. Participants first completed the prototype intervention independently and were then shown the intervention page by page and asked to verbalise their thoughts and experiences. Transcripts were analyzed thematically.

RESULTS

Participants found the intervention helpful. Four themes were generated - 'Educative: Learning, but more fun', 'Effortless: Quicker and Easier', 'Personalization: Power of Choice', and 'Positivity: Just Good Vibes'. The theme 'Educative: Learning, but more fun' encompassed two sub-themes 'Opportunity to Learn' and 'Aesthetics and Learning'. These themes reflected participants' views that the intervention was educative, personalised, solution-oriented and easy to use, but could incorporate more graphics and visuals to aid in learning and could be made more effortless and positive through modifications to its design.

CONCLUSIONS

Findings convey the importance of ensuring educative well-designed content, personalization, a positive tone, and ease of use while designing interventions targeting adolescents's sleep and mental health. They also indicate areas for further developing the intervention.

Investigation of the Association between Sleep Disorders with Subsequent Depression in Children and Adolescents-A Retrospective Cohort Study with 62,796 Patients

BACKGROUND

Poor quality of sleep is a widespread issue in modern society, and even children are being diagnosed with sleep disorders nowadays. Sleep disruption in children can lead to poor mental health in the long term. The present study aimed to evaluate the association between sleep disorders and subsequent depression in children and adolescents.

METHODS

This retrospective cohort study used electronic medical records from the IQVIATM Disease Analyzer database. It included children and adolescents aged 6-16 with an initial diagnosis of a sleep disorder and age- and gender-matched patients without sleep disorders treated by one of 274 office-based pediatricians in Germany between January 2010 and December 2022. The five-year cumulative incidence of depression in the cohorts with and without sleep disorders was studied with Kaplan-Meier curves using the log-rank test. Multivariable Cox regression analyses were used to assess the association between sleep disorders and depression.

RESULTS

The present study included 10,466 children and adolescents with and 52,330 without sleep disorder diagnosis (mean age 10 ± 3 years, 48% female). Within five years after the index date, 5% of sleep disorder patients and 2% of the matched non-sleep disorder cohort had been diagnosed with depression. A strong and significant association was observed between sleep disorders and subsequent depression (HR: 2.34; 95% CI: 2.09-2.63). This association was stronger in adolescents (HR: 3.78; 95% CI: 3.13-4.56) than in children. Upon the exclusion of depression diagnoses in the first year after the index date, the association between sleep disorders and depression remained strong and significant (HR: 1.92; 95% CI: 1.68-2.19).

CONCLUSIONS

This study indicates a strong and significant association between sleep disorders and depression.

Emotional Dysregulation and Sleep Problems: A Transdiagnostic Approach in Youth

BACKGROUND

Sleep is a complex phenomenon that affects several aspects of life, including cognitive functioning, emotional regulation, and overall well-being. Sleep disturbances, especially during adolescence, can negatively impact emotional regulation, making it a critical factor in targeting psychopathology.

METHODS

This study explores the interplay between emotional dysregulation (ED) and sleep patterns in a sample of 90 adolescent patients by means of self- and parent-rated clinical measures.

RESULTS

Our findings reveal a bidirectional relationship between ED and sleep problems. Adolescents with higher affective instability experience poorer sleep quality, while those with worse sleep quality exhibit higher internalizing problems. Additionally, emotional reactivity is associated with disrupted circadian rhythms.

CONCLUSIONS

These results emphasize the significance of addressing sleep problems in the context of psychopathology treatment, potentially leading to improved outcomes. Further research is needed to determine the most effective treatment strategies, including nonpharmacological and pharmacological interventions. Understanding the intricate relationship between sleep problems and emotion regulation offers insights for more targeted and effective treatment approaches for youths struggling with ED.

Sleep disruption in adolescent inpatients: prevalence, associations with clinical outcomes, and clinician perspectives

Sleep problems are common for adolescents with psychiatric disorders, and sleep treatment may aid mental health recovery. Inpatient admissions are likely a particularly challenging time for sleep. Despite this little is known about the nature of sleep problems, and how sleep treatments could be optimised for this setting. This mixed-methods study set out to better understand sleep disturbances in adolescent inpatients. Study 1 examined the prevalence of Sleep Condition Indicator-assessed insomnia at admission and associations with psychiatric symptoms and admission length in 100 inpatients (aged 11-17 years) on one unit in Oxford. Data were gathered from admission routine measures and medical records. Associations were analysed using linear regressions. Half of the inpatients (n = 50) screened positive for insomnia at admission. Moderate-large significant associations were observed between more severe insomnia and more severe depression (β = -0.56), anxiety (β = -0.51), self-harm (β = -0.49), psychotic experiences (β = -0.32), and conduct problems (β = -0.30), but not admission length. Study 2 gained 12 clinicians' perspectives on sleep problems on the unit via a focus group and semi-structured interviews, analysed using thematic analysis. Ward staff observed insomnia and excessive daytime sleepiness in adolescent inpatients and a reciprocal relationship with mental health symptoms. Ward processes were barriers (e.g., night-time observations) and facilitators (e.g., regular routines) of sleep. Cognitive behavioural therapy for insomnia was not routinely offered but viewed as potentially helpful. Insomnia may be a common problem for adolescent inpatients, associated with greater psychopathology, but not admission length. The possible benefits of psychological sleep interventions for adolescents admitted to psychiatric units now require testing.

Exploring the relationship between sleep and aggression in adolescents: A cross sectional study using the UK Millennium cohort study

This study aimed to establish if a significant relationship exists between sleep and aggression in a large representative adolescent cohort and explores the impact of potential confounders. This cross-sectional secondary data analysis included 10,866 males and females aged 13-15 years, from the UK-based 2015 Millenium Cohort Study (sixth sweep). Independent variables included self-report measures of sleep duration and quality. The parent reported 'Strengths and Difficulties Questionnaire' conduct score measured aggression. Binary logistic regression examined independent associations between each sleep variable and aggression. Multiple regression models then adjusted for potential confounders: age, sex, socioeconomic status, arousal, and affect. Under 8 hours of sleep on average was significantly associated with aggression when age, sex and income were controlled (p = .008). This became insignificant following adjustment for both affect and arousal. Sleep quality remained significantly associated with aggression when all confounders were controlled: 'sleep onset latency >30 minutes' and 'wakening at least a good bit of the time' increased the odds of aggression by around 27.9% (p < .001) and 43.5% respectively (p < .001). A significant association exists between poor subjective sleep quality and heightened aggression in this cohort, when all our confounders are controlled, identifying sleep quality as a potential target in treating adolescent aggression.

The Associations Between Sleep and Externalizing and Internalizing Problems in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: Empirical Findings, Clinical Implications, and Future Research Directions

Sleep problems are common in youth with attention-deficit/hyperactivity disorder (ADHD). Externalizing and internalizing problems contribute to dysfunction in youth with ADHD and are amplified by disrupted sleep. This objective of this article is to synthesize empirical studies that examined the associations between sleep and internalizing or externalizing problems in individuals with ADHD. The main findings are that sleep problems precede, predict, and significantly contribute to the manifestation of internalizing and externalizing behavior problems among children and adolescents with ADHD. Clinicians should assess sleep and integrate sleep interventions into the management of youth with ADHD.

Preliminary study: cognitive behavioural therapy for insomnia in adolescents with anorexia nervosa

PURPOSE

Insomnia and anorexia nervosa (AN) are frequently comorbid, negatively affecting the evolution and the prognosis of AN. Within this framework, the management of sleep disorders appears as critical. The aim of this retrospective study is to assess, for the first time, the efficacy of cognitive and behavioural therapy for insomnia (CBT-I) on sleep disturbances in adolescents with AN. To do so, we investigated the impact of CBT-I on sleep disturbances and sleep-related outcomes, in BMI, AN symptoms, anxiety and depressive symptoms, emotionality and quality of life. These features were compared between two groups of patients with AN, one following CBT-I, and the other receiving the regular treatment at the psychiatric unit.

METHODS

Data collection occurred between January and May 2022. The study included 42 adolescents in-treatment at the Eating Disorders care specialised unit at Salvator Hospital in Marseille. They were randomly assigned to the CBT-I group (N = 31) or the control group (N = 11). Several clinical elements were assessed using sleep diaries and self-report questionnaires.

RESULTS

Participants undergoing CBT-I showed a significant improvement in sleep latency, total wake time and sleep efficacy, as well as in physical well-being. No significant effects were found regarding AN symptoms.

CONCLUSION

These preliminary findings provide support for CBT-I effectiveness in adolescents with AN, as shown by significant improvements in several sleep parameters, as well as in physical well-being. These promising results, underline the relevance of this topic and its potential benefits for a more appropriate treatment for adolescents with AN.

LEVEL OF EVIDENCE

Level V, retrospective study.

Transdiagnostic Sleep and Circadian Intervention for Adolescents Plus Text Messaging: Randomized Controlled Trial 12-month Follow-up

OBJECTIVE

The Transdiagnostic Sleep and Circadian Intervention for Youth (TranS-C) was developed to improve sleep and circadian functioning in adolescents. This study examined the 12-month effects for TranS-C compared with psychoeducation (PE). We also investigated whether a text messaging intervention can promote maintenance of treatment effects.

METHOD

At the baseline, adolescents (58% female, average age = 14.8 years) with an eveningness chronotype were randomized to TranS-C (n = 89) or PE (n = 87). At 6-month follow-up, participants were randomized to receive text messages that had repeated treatment information (n = 47), text messages that prompted the recall of treatment information (n = 50), or no text messages (n = 47).

RESULTS

Relative to PE, TranS-C was associated with a reduced eveningness (b = 2.06, p = .005, d = 0.29) from the baseline to a 12-month follow-up. TranS-C treatment effects, relative to PE, were augmented by receiving text messages, compared to no text messages, for eveningness from baseline to 12-month follow-up (b = 1.38, p = .008, d = 0.28) and from 6- to 12-month follow-up (b = 1.07, p = .046, d = 0.21). Neither TranS-C nor text messages were significantly associated with other primary outcomes. TranS-C and text messages were significantly associated with improvements on selected secondary sleep and health outcomes through follow-up.

CONCLUSIONS

For adolescents with an eveningness chronotype, improved sleep and circadian functioning on selected outcomes were maintained over 12 months for TranS-C compared with PE. Text messages boosted the effects of TranS-C through 12-month follow-up.

Earlier Bedtime and Its Effect on Adolescent Sleep Duration

BACKGROUND AND OBJECTIVES

Sleep duration decreases by ∼10 minutes per year throughout adolescence. A circadian phase delay and changes in homeostatic sleep regulation enable adolescents to stay up later. We determine if teens are able to increase sleep duration by advancing bedtime and whether this ability changes with age.

METHODS

A younger cohort of 77 participants ranging in age from 9.9 to 16.2 years were studied annually for 3 years. An older cohort of 67 participants ranging in age from 15.0 to 20.6 years was studied only once. Annually, participants kept each of 3 different time in bed (TIB) schedules (7, 8.5, and 10 hours) for 4 consecutive nights. Participants kept their habitual weekday rise times; TIB was altered by advancing bedtimes. We report polysomnography-measured sleep durations from the fourth night of the TIB schedule.

RESULTS

Despite increases in sleep onset latency and wake after sleep onset, sleep duration increased with TIB as bedtime was advanced. Average (SE) sleep duration increased from 402.8 (1.6) minutes with 7 hours to 470.6 (2.1) minutes with 8.5 hours to 527.5 (3.0) minutes with 10 hours TIB. Sleep duration decreased with age (1.55 [0.48] minutes/year), but the TIB effect on sleep duration did not (TIB by age interaction, P = .42).

CONCLUSIONS

Adolescents can substantially increase sleep duration by advancing bedtime, and this ability does not change between ages 10 and 21 years. Additional research is needed to determine how to translate these findings from experiment-controlled sleep schedules to real-world sleep duration increases.

Sleep IntervEntion as Symptom Treatment for ADHD (SIESTA)-Blended CBT sleep intervention to improve sleep, ADHD symptoms and related problems in adolescents with ADHD: Protocol for a randomised controlled trial

INTRODUCTION

Adolescents with attention deficit hyperactivity disorder (ADHD) experience a more disrupted sleep and more sleep problems compared with typically developing adolescents. This is particularly concerning, because disrupted sleep is related to worsened clinical, neurocognitive and functional outcomes and leads to increased ADHD symptom impairment. Due to the specific difficulties adolescents with ADHD experience, a tailored sleep treatment is needed. Therefore, our lab developed a cognitive behavioural treatment-Sleep IntervEntion as Sympom Treatment for ADHD (SIESTA)-that integrates sleep training with motivational interviewing, and planning/organisational skills training with the aim of improving sleep problems in adolescents with ADHD.

METHODS AND ANALYSIS

A randomised, controlled, investigator-blinded monocentre trial is used to test whether SIESTA in combination with treatment as usual (TAU) for ADHD results in greater improvement in sleep problems than TAU only. Adolescents (aged 13-17 years) with ADHD and sleep problems are included. They complete measurements before treatment (pre-test), approximately 7 weeks after the pre-test (post-test), and approximately 3 months after the post-test (follow-up). The assessment includes questionnaires filled out by adolescents, parents and teachers. Additionally, sleep is assessed by actigraphy and sleep diaries at all time-points. Primary outcomes include objectively and subjectively measured sleep architecture (specified as total sleep time, sleep onset latency, sleep efficiency and number of awakenings), subjectively measured sleep problems and sleep hygiene. Secondary outcomes include ADHD symptoms, comorbidities and functional outcomes. To analyse the data, a linear mixed effects model will be used with an intent-to-treat approach.

ETHICS AND DISSEMINATION

The study activities, informed consent and assent forms have been approved by the Ethical Committee Research UZ/KU Leuven (study ID S64197). If proven effective, the intervention will be implemented throughout Flanders. Therefore, an advisory board consisting of societal partners in healthcare is appointed at the start of the project, giving advice throughout the project and assistance with implementation afterwards.

TRIAL REGISTRATION NUMBER

NCT04723719.

Associations of social jetlag and insomnia symptoms with depressive symptoms among Chinese adolescents: A large population-based study

OBJECTIVE

This study aimed to evaluate the associations of social jetlag and insomnia symptoms with depressive symptoms among adolescents.

METHODS

A total of 37,871 junior high students completed an online survey between May 24th and Jun 5th, 2022. Insomnia symptoms were assessed by three items based on the Diagnostic and Statistical Manual of Mental Disorders criteria. Social jetlag and depressive symptoms were evaluated by the Munich Chronotype Questionnaire and the Patient Health Questionnaire, respectively. Restricted cubic splines were used to explore the relationship between social jetlag and depressive symptoms. Joint effects of social jetlag and insomnia symptoms on depressive symptoms were estimated using additive interaction models.

RESULTS

The prevalence of depressive symptoms was 13.1%. Depressive symptoms were more common in adolescents with social jetlag ≥2 h (OR: 1.51, 95% CI: 1.39-1.65) and insomnia symptoms (OR: 6.91, 95% CI: 6.41-7.44). There was a J-shaped relationship between social jetlag and depressive symptoms when we took social jetlag as a continuous variable. Moreover, a positive additive interaction of social jetlag ≥2 h and insomnia symptoms on depressive symptoms was found in female adolescents (RERI: 2.30, 95% CI: 0.11-4.49).

CONCLUSIONS

Our findings suggested that social jetlag ≥2 h and insomnia are related to the occurrence of depressive symptoms in adolescents. Their coexistence additively enhances the strength of the association with depressive symptoms. Early screening and intervention for insomnia, as well as methods to reduce social jetlag, should be comprised as part of preventive strategies for depression in adolescents.

Sleep Deprivation and Insomnia in Adolescence: Implications for Mental Health

Sleep changes significantly throughout the human lifespan. Physiological modifications in sleep regulation, in common with many mammals (especially in the circadian rhythms), predispose adolescents to sleep loss until early adulthood. Adolescents are one-sixth of all human beings and are at high risk for mental diseases (particularly mood disorders) and self-injury. This has been attributed to the incredible number of changes occurring in a limited time window that encompasses rapid biological and psychosocial modifications, which predispose teens to at-risk behaviors. Adolescents' sleep patterns have been investigated as a biunivocal cause for potential damaging conditions, in which insufficient sleep may be both a cause and a consequence of mental health problems. The recent COVID-19 pandemic in particular has made a detrimental contribution to many adolescents' mental health and sleep quality. In this review, we aim to summarize the knowledge in the field and to explore implications for adolescents' (and future adults') mental and physical health, as well as to outline potential strategies of prevention.

A feasibility study to explore the use of digital treatment of sleep as a first-step intervention to improve adolescent mental health

INTRODUCTION

Cognitive behavior therapy for insomnia (CBTi), delivered face-to-face or digitally, can improve the mental health of adults. Although insomnia is common in adolescents, the effects of digital CBTi on adolescent mental health have seldom been investigated.

OBJECTIVES

The aims of this study were to explore: (i) the acceptability of a digital CBTi intervention, Sleepio, as a first-step intervention for adolescents referred to specialist mental health services (CAMHS), (ii) the impact on sleep and mental health and (iii) subsequent CAMHS interventions.

METHOD

Sleepio is a computerized CBTi intervention comprised of six sequentially delivered sessions. Digital Sleepio was offered to new referrals to CAMHS with poor sleep and mental health problems. Results. Of the 75 eligible adolescents, 70 (93%; 95% CI: 85% to 98%) accepted Sleepio with 59 starting the programme and consenting to participate in the study. Of these, 37 (63%; 95% CI: 49% to 75%) completed at least half of the programme. There were post-intervention improvements in sleep, mood, and anxiety; the improvement in sleep was greater for those who completed at least half the programme compared to those who did not. Of those who completed all the programme, 55% (15/29) did not need any subsequent specialist CAMHS input. Of the 11 adolescents who accepted but never started Sleepio, none engaged with other CAMHS interventions and were subsequently discharged.

CONCLUSION

Our study has a number of limitations, in particular the absence of a control group and the loss of follow-up data for programme drop-outs. Nonetheless, these results suggest that digital CBTi may offer a novel and acceptable way of improving the sleep and mental health of adolescents with insomnia. A fully powered randomized controlled trial is required to obtain definitive estimates of the effects of the intervention.

Efficacy of Cognitive Behavioral Therapy for Insomnia for the Treatment of Child and Adolescent Anxiety and Depression: A Systematic Review From Randomized Controlled Trials

ABSTRACT

Cognitive behavioral therapy for insomnia (CBT-I) has shown promising results in the adult population. However, there is not enough evidence for children and adolescents. Hence, we evaluated the current evidence of CBT-I in the treatment of anxiety and depression in children and adolescents. Published randomized clinical trials published before June 2020 were searched from PubMed, Cochrane Library of database, clinicaltrials.gov, and Google Scholar. Out of seven included studies, six studies assessed the effect of CBT-I on depression, and five assessed the effect on anxiety. In this review, most studies in this review showed a strong effect of CBT-I on symptoms of depression. Although a positive effect of CBT-I on anxiety was noted, only a small number of studies have considered this management. These findings should be considered preliminary, and further large-scale studies are warranted to further explore this finding further.

Sleep During the Pandemic

The coronavirus disease 2019 (COVID-19) pandemic has significantly affected childhood sleep. Decreased sleep quality and duration, more bedtime resistance, difficulty initiating and maintaining sleep, and higher rates of parasomnias have all been noted. The mental health crisis with doubling rates of anxiety and depression has also had a profound influence on youth sleep. The pediatric sleep medicine field has responded to the COVID-19 pandemic by adapting existing practices for safety and greatly expanding telemedicine services. Research and training considerations are further discussed.

Insomnia in Infancy, Childhood, and Adolescence

Insomnia is the most prevalent sleep disorder in youth, tends to persist over time, and is associated with a myriad of adverse outcomes. This paper synthesizes the current evidence regarding the phenomenology, prevalence, assessment, consequences, cause, and treatment of pediatric insomnia, highlighting areas that warrant further research and addressing the unique characteristics of this disorder in infants, children, and adolescents.

Mobile phone use addiction, insomnia, and depressive symptoms in adolescents from ethnic minority areas in China: A latent variable mediation model

BACKGROUND AND AIMS

Although previous studies have discussed the association between mobile phone use addiction (MPUA) and depressive symptoms in adolescents, studies on Chinese adolescents are limited, with no studies being reported on adolescents from ethnic minority areas within Yunnan. This study aimed to explore the mediating mechanism of insomnia in the association between MPUA and depressive symptoms among Yunnan college students.

METHODS

A sample survey was conducted among 10,121 college students from four colleges in Yunnan province, China, from November to December 2021 via cluster sampling. Insomnia was assessed using the Insomnia Severity Index Scale, MPUA was assessed using the Self-Rating Questionnaire for Adolescent Problematic Mobile Phone Use, and depressive symptoms were assessed using the Patient Health Questionnaire-9 items. A generalized linear model was used to analyze the association between MPUA, insomnia, and depressive symptoms. The structural equation model was used to analyze the mediating effect of insomnia.

RESULTS

The positive rates of depressive symptoms, MPUA, and insomnia were 39.2 %, 30.8 %, and 22.3 %, respectively. After adjusting for the demographic and confounding variables, MPUA (β = 0.14, 95 % CI: 0.13-0.15, P < 0.01) and insomnia (β = 0.44, 95 % CI: 0.43-0.46, P < 0.01) were associated with depressive symptoms (P < 0.05). The mediating effect of insomnia accounted for 34.7 % of the total effect in the mediating model of MPUA associated with depressive symptoms.

CONCLUSION

Our findings suggest that insomnia partially mediates the association between MPUA and depressive symptoms among Yunnan college students.

Effects of schedule exercise therapy on chronic insomnia

Schedule exercise therapy (SET) is a novel nonpharmacological intervention for the treatment of chronic insomnia disorder (CID). The aim of this study was to explore the effects of SET on CID. Methods: One hundred and eighteen CID were recruited and randomized into medication (MED) or medication combined with SET (MSET) groups. Over 12 observational weeks, sleep and mood status were evaluated using the Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Epworth Sleepiness Scale (ESS), Self-rating Depression Scale (SDS), and Self-rating Anxiety Scale (SAS). At the end of the observational period, the rates of clinically effective hypnotic use were calculated. At 12 weeks, the PSQI progressively decreased for all subjects combined (P < .001) as well as ISI (P < .001), ESS (P < .001), SDS (P < .001), and SAS (P < .001). The decreases in PSQI (P < .05), ISI (P < .05), SDS (P < .01), and SAS (P < .05) in the MSET group were significantly larger than those in the MED group, but not the same as those in the ESS group (P > .05). At the trial endpoint, the clinically effective rate was significantly higher (P < .05) and the hypnotic usage rate was lower (P < .05) in the MSET group than in the MED group. SET may be an effective treatment for insomnia in patients with CID.

Back to Basics: Lifestyle Interventions for Adolescent Depression

LEARNING OBJECTIVES

After completing this activity, practitioners will be better able to:• Discuss and better understand the recently adopted screening standards for adolescents with depression and the potential advantages of using "lifestyle medicine"• Set up a process for providing effective interventions for the increased number of patients with adolescent depression• Design or update their toolbox of treatment options for adolescents with depression based on the new literature and increased demand.

ABSTRACT

Recently adopted quality standards recommend that pediatricians screen adolescents for depression and that they document follow-up plans for those who screen positive. As a result of these new recommendations, pediatricians and other pediatric providers, as well as psychiatrists and other mental health professionals, may face an increasing number of referrals and a growing need for effective interventions for adolescent depression. Given the widely acknowledged scarcity of traditional mental health resources, the current study reviewed the rapidly expanding array of evidence-based, but nontraditional, interventions applicable to outpatient pediatric and mental health care settings. Many of these interventions come from a lifestyle medicine framework. Lifestyle medicine interventions are congruent with the cultures of pediatrics and outpatient psychiatry, and offer additional evidence-based tools for providers managing adolescent depression. These interventions can be implemented individually or within group or community settings, and may be used in conjunction with more common interventions such as psychotherapy or psychotropic medications.

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

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

Sleep to Internalizing Pathway in Young Adolescents (SIPYA): A proposed neurodevelopmental model

The prevalence of internalizing disorders, i.e., anxiety and depressive disorders, spikes in adolescence and has been increasing amongst adolescents despite the existence of evidence-based treatments, highlighting the need for advancing theories on how internalizing disorders emerge. The current review presents a theoretical model, called the Sleep to Internalizing Pathway in Young Adolescents (SIPYA) Model, to explain how risk factors, namely sleep-related problems (SRPs), are prospectively associated with internalizing disorders in adolescence. Specifically, SRPs during late childhood and early adolescence, around the initiation of pubertal development, contribute to the interruption of intrinsic brain networks dynamics, both within the default mode network and between the default mode network and other networks in the brain. This interruption leaves adolescents vulnerable to repetitive negative thought, such as worry or rumination, which then increases vulnerability to internalizing symptoms and disorders later in adolescence. Sleep-related behaviors are observable, modifiable, low-stigma, and beneficial beyond treating internalizing psychopathology, highlighting the intervention potential associated with understanding the neurodevelopmental impact of SRPs around the transition to adolescence. This review details support for the SIPYA Model, as well as gaps in the literature and future directions.

Testing Bidirectional, Longitudinal Associations Between Disturbed Sleep and Depressive Symptoms in Children and Adolescents Using Cross-Lagged Models

IMPORTANCE

Understanding the longitudinal, bidirectional associations between disturbed sleep and depression in childhood and adolescence is crucial for the development of prevention and intervention programs.

OBJECTIVE

To test for bidirectional associations and cascade processes between disturbed sleep and depressive symptoms covering both childhood and adolescence and to test for the moderating processes of sex and pubertal status in adolescence.

DESIGN, SETTING, AND PARTICIPANTS

A prospective cohort study using the Québec Longitudinal Study of Child Development (QLSCD; 1997-ongoing). QLSCD's objective is to identify early childhood factors associated with long-term psychosocial and academic adjustment. Data were collected across 8 waves between ages 5 years (2003) and 17 years (2015). Associations were tested through cross-lagged models in childhood (5, 7, and 8 years), and in adolescence (10, 12, 13, 15, and 17 years). Data were analyzed from February to October 2021.

MAIN OUTCOMES AND MEASURES

Primary outcomes were disturbed sleep and depressive symptoms. Disturbed sleep was parent-reported and included sleep duration, time awake in bed, daytime sleepiness, sleep talking, sleepwalking, night terrors, and nightmares. Depressive symptoms were parent-reported in childhood (Child Behavior Checklist and Revised Ontario Child Health Study Scales), and self-reported in adolescence (Mental Health and Social Inadaptation Assessment for Adolescents).

RESULTS

Data on 1689 children (852 female [50.4%]) and 1113 adolescents (595 female [53.5%]) were included in the analyses. In childhood, significant bidirectional associations between depressive symptoms and disturbed sleep at all time points were found, indicating cascade processes (range β = 0.07; 95% CI, 0.02-012 to β = 0.15; 95% CI, 0.10-0.19). In adolescence, significant bidirectional associations from depressive symptoms to disturbed sleep (β = 0.09; 95% CI, 0.04-0.14) and vice versa (β = 0.10; 95% CI, 0.04-0.16) between 10 and 12 years were found. Between 12 and 13 years, depressive symptoms were modestly associated with disturbed sleep (β = 0.05; 95% CI, 0.001-0.10) but the reverse association was not significant. Cross-lagged estimates were nonsignificant after 13 years. The associations did not vary as a function of either sex or puberty-by-sex.

CONCLUSIONS AND RELEVANCE

These findings suggest that disturbed sleep is associated with the consolidation of depressive symptoms starting in childhood, which, in turn, is associated with ongoing sleep problems. It is possible that timely and appropriate interventions for incipient disturbed sleep and depression prevent spiraling effects on both domains.

Relationship of overweight and obesity to insomnia severity, sleep quality, and insomnia improvement in a clinically referred pediatric sample

STUDY OBJECTIVES

Children with overweight or obesity are more likely to experience sleep disorders, although the role of weight in pediatric insomnia treatment has not been examined. The current study examined the relationships of high body mass with pretreatment insomnia severity and global sleep problems and the potential moderating impact of weight on changes in insomnia severity following insomnia treatment.

METHODS

Participants included 1,133 youth ages 2-18 years clinically referred for insomnia treatment. The Pediatric Insomnia Severity Index was collected at the initial assessment and throughout treatment as part of routine clinical care. Treatment status was coded as no treatment, early termination, and completed treatment. Secondary measures of global sleep problems at the initial assessment included the Adolescent Sleep Wake Scale, Adolescent Sleep Hygiene Scale, and Children's Sleep Habits Questionnaire. Medical chart review of visits within ± 3 months of baseline was used to obtain age-adjusted and sex-adjusted body mass index Z-score.

RESULTS

Among adolescents, regression analyses found that higher body mass index Z-score modestly predicted baseline insomnia severity (P = .021) and worse sleep hygiene (P < .001). For children, higher body mass index Z-score was modestly associated with baseline total sleep problems (P = .006) but not insomnia severity (P = .792). Across ages, body mass index Z-score predicted neither treatment status nor insomnia improvement (P > .05). Findings were similar in categorical analyses comparing patients with overweight/obesity to healthy weight.

CONCLUSIONS

Although there is evidence that children of higher body mass present for insomnia treatment with greater sleep concerns, body mass does not predict treatment completion or insomnia improvement. Data suggest insomnia treatment is effective irrespective of weight status.

CITATION

Duraccio KM, Simmons DM, Beebe DW, Byars KC. Relationship of overweight and obesity to insomnia severity, sleep quality, and insomnia improvement in a clinically referred pediatric sample. J Clin Sleep Med. 2022;18(4):1083-1091.

Effectiveness of Digital Cognitive Behavioral Therapy for Insomnia in Young People: Preliminary Findings from Systematic Review and Meta-Analysis

Various forms of cognitive behavioral therapy for insomnia (CBT-i) have been developed to improve its scalability and accessibility for insomnia management in young people, but the efficacy of digitally-delivered cognitive behavioral therapy for insomnia (dCBT-i) remains uncertain. This study systematically reviewed and evaluated the effectiveness of dCBT-i among young individuals with insomnia. We conducted comprehensive searches using four electronic databases (PubMed, Cochrane Library, PsycINFO, and Embase; until October 2021) and examined eligible records. The search strategy comprised the following three main concepts: (1) participants were adolescents or active college students; (2) dCBT-I was employed; (3) standardized tools were used for outcome measurement. Four randomized controlled trials qualified for meta-analysis. A significant improvement in self-reported sleep quality with a medium-to-large effect size after treatment (Hedges’s g = −0.58~−0.80) was noted. However, a limited effect was detected regarding objective sleep quality improvement (total sleep time and sleep efficiency measured using actigraphy). These preliminary findings from the meta-analysis suggest that dCBT-i is a moderately effective treatment in managing insomnia in younger age groups, and CBT-i delivered through the web or a mobile application is an acceptable approach for promoting sleep health in young people.

Prevalence of Sleep Disorders, Risk Factors and Sleep Treatment Needs of Adolescents and Young Adult Childhood Cancer Patients in Follow-Up after Treatment

BACKGROUND

Sleep disorders negatively impact adolescent and young adult childhood cancer patients' physical and psychosocial health. Early recognition improves timely treatment. We therefore studied the prevalence of subjective sleep disorders, risk factors and sleep treatment needs after completion of childhood cancer treatment.

METHODS

Childhood cancer patients (12-26 years old), ≥6 months after treatment, were invited to fill out the Holland Sleep Disorders Questionnaire, which distinguishes six sleep disorders in substantial agreement with the International Classification of Sleep Disorders, second edition (ICSD-2). They additionally indicated sleep treatment needs. Prevalence rates and needs were displayed in percentages. Logistic regression models were used for risk factors.

RESULTS

576 patients participated (response rate 55.8%)-49.5% females, mean age 17.0 years, 44.4% hemato-oncology, 31.9% solid tumors, 23.6% neuro-oncology. Prevalence rates were: insomnia (9.6%), circadian rhythm sleep disorder (CRSD; 8.1%), restless legs syndrome (7.6%), parasomnia (3.5%), hypersomnia (3.5%) and sleep-related breathing disorders (1.8%). Female sex, comorbid health conditions and young adulthood seem to be risk factors for sleep disorders, but cancer-related factors were not. Differing per sleep disorder, 42-72% wanted help, but only 0-5.6% received sleep treatment.

CONCLUSIONS

Insomnia and CRSD were most prevalent. An unmet need for sleep treatment was reported by childhood cancer patients during follow-up. Screening for sleep disorders after cancer might improve access to treatment and patient wellbeing.

Theories of Change and Mediators of Psychotherapy Effectiveness in Adolescents With Externalising Behaviours: A Systematic Review

BACKGROUND

Externalising behaviours are becoming a remarkably prevalent problem during adolescence, often precipitating both externalising and internalising disorders in later adulthood. Psychological treatments aim to increase the social functioning of adolescents in order for them to live a more balanced life and prevent these negative trajectories. However, little is known of the intervening variables and mediators involved in these treatments' change mechanisms. We conducted a systematic review, exploring the available evidence on mediators of psychological treatments for externalising behaviours and symptoms amongst adolescents (10 to 19 years old).

METHODS

A systematic search was performed on Medline and PsycINFO databases, which identified studies from inception to February 23, 2020. Eligible studies included randomised controlled trials that enrolled adolescents with externalising symptoms and behaviours as, at least, one of the primary outcomes. A group of 20 reviewers from the COST-Action TREATme (CA16102) were divided into 10 pairs. Each pair independently screened studies for inclusion, extracted information from the included studies, and assessed the methodological quality of the included studies and the requirements for mediators, following Kazdin's criteria. Risk of bias of RCTs was assessed by the Mixed Methods Appraisal Tool. Extracted data from the included studies were reported using a narrative synthesis.

RESULTS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA), after removing duplicates, 3,660 articles were screened. Disagreements were resolved by consensus. In a second stage, 965 full-text articles were assessed for eligibility. A total of 14 studies fulfilled all inclusion criteria. The majority were related to systemic psychological treatment approaches. Two types of mediators were identified as potentially being involved in the mechanisms of change for better social improvements of adolescents: to increase healthier parent-adolescent relationships and parental discipline. However, there were significant and non-significant results amongst the same mediators, which led to discussing the results tentatively.

CONCLUSIONS

Family variables were found to be the largest group of investigated mediators, followed by relational, behavioural, and emotional variables. No cognitive or treatment-specific mediators were identified. Both adequate behavioural control of adolescents' peer behaviour and a better positive balance in their relationships with their parents seemed to buffer the effects of externalising behaviours in adolescents. Several methodological limitations concerning mediation testing design, outcome measures, and mediator selection have been identified.

ETHICS AND DISSEMINATION

Ethical approval was not required. PROSPERO registration number: CRD42021231835.

Mechanisms of Change in Digital Health Interventions for Mental Disorders in Youth: Systematic Review

BACKGROUND

Digital health interventions (DHIs) are efficacious for several mental disorders in youth; however, integrated, evidence-based knowledge about the mechanisms of change in these interventions is lacking.

OBJECTIVE

This systematic review aims to comprehensively evaluate studies on mediators and mechanisms of change in different DHIs for common mental disorders in children and adolescents.

METHODS

A systematic literature search of the electronic databases Cochrane Central Register of Controlled Trials, Embase, MEDLINE, and PsycINFO was conducted, complemented by backward and forward searches. Two independent reviewers selected studies for inclusion, extracted the data, and rated the methodological quality of eligible studies (ie, risk of bias and 8 quality criteria for process research).

RESULTS

A total of 25 studies that have evaluated 39 potential mediators were included in this review. Cognitive mediators were the largest group of examined intervening variables, followed by a broad range of emotional and affective, interpersonal, parenting behavior, and other mediators. The mediator categories with the highest percentages of significant intervening variables were the groups of affective mediators (4/4, 100%) and combined cognitive mediators (13/19, 68%). Although more than three-quarters of the eligible studies met 5 or more quality criteria, causal conclusions have been widely precluded.

CONCLUSIONS

The findings of this review might guide the empirically informed advancement of DHIs, contributing to improved intervention outcomes, and the discussion of methodological recommendations for process research might facilitate mediation studies with more pertinent designs, allowing for conclusions with higher causal certainty in the future.

Do non-pharmacological sleep interventions affect anxiety symptoms? A meta-analysis

Research indicates a bidirectional relationship between sleep and anxiety, with findings suggesting anxiety can precede poor sleep and vice versa. Evidence suggests sleep-related thought processes associated with anxiety are involved in the maintenance of insomnia. Previous meta-analyses provide some evidence to suggest cognitive behavioural therapy for insomnia moderately improves anxiety, yet little research has investigated the effect of other sleep interventions on anxiety symptoms. The aim of this meta-analysis was to review whether non-pharmacological sleep interventions have an impact on anxiety symptoms immediately post-intervention. A systematic search of electronic databases was conducted to identify all randomized control trials (RCTs) investigating non-pharmacological sleep interventions that included anxiety symptoms as an outcome. Forty-three RCTs (n = 5945) met full inclusion criteria and were included in a random-effects meta-analysis model. The combined effect size of non-pharmacological sleep interventions on anxiety symptoms was moderate (Hedges' g = -0.38), indicating a reduction in symptoms. Subgroup analyses found a moderate effect for those with additional physical health difficulties (g = -0.46), a moderate effect for those with additional mental health difficulties (g = -0.47) and a moderate effect for those with elevated levels of anxiety at baseline (g = -0.43). A secondary meta-analysis found a large effect of non-pharmacological sleep interventions on sleep-related thought processes (g = -0.92). These findings indicate non-pharmacological sleep interventions are effective in reducing anxiety and sleep-related thought processes, and these effects may be larger in patients with anxiety. This has clinical implications for considering sleep interventions in the treatment of anxiety.

Association Between Disturbed Sleep and Depression in Children and Youths: A Systematic Review and Meta-analysis of Cohort Studies

IMPORTANCE

Disturbed sleep represents a potentially modifiable risk factor for depression in children and youths that can be targeted in prevention programs.

OBJECTIVE

To evaluate the association between disturbed sleep and depression in children and youths using meta-analytic methods.

DATA SOURCES

Embase, MEDLINE, PsycINFO, Scopus, Web of Science, and ProQuest Dissertations & Theses Global were searched for articles published from 1980 to August 2019.

STUDY SELECTION

Prospective cohort studies reporting estimates, adjusted for baseline depression, of the association between disturbed sleep and depression in 5- to 24-year-old participants from community and clinical-based samples with any comorbid diagnosis. Case series and reports, systematic reviews, meta-analyses, and treatment, theoretical, and position studies were excluded. A total of 8700 studies met the selection criteria. This study adhered to the guidelines of the Preferred Reporting Items for Systematic Reviews (PRISMA) and Meta-analyses and the Meta-analysis of Observational Studies in Epidemiology (MOOSE) statements.

DATA EXTRACTION AND SYNTHESIS

Study screening and data extraction were conducted by 2 authors at all stages. To pool effect estimates, a fixed-effect model was used if I2 < 50%; otherwise, a random-effects model was used. The I2 statistic was used to assess heterogeneity. The risk of bias was assessed using the Research Triangle Institute Item Bank tool. Metaregression analyses were used to explore the heterogeneity associated with type of ascertainment, type of and assessment tool for disturbed sleep and depression, follow-up duration, disturbed sleep at follow-up, and age at baseline.

MAIN OUTCOME AND MEASURES

Disturbed sleep included sleep disturbances or insomnia. Depression included depressive disorders or dimensional constructs of depression. Covariates included age, sex, and sociodemographic variables.

RESULTS

A total of 22 studies (including 28 895 patients) were included in the study, of which 16 (including 27 073 patients) were included in the meta-analysis. The pooled β coefficient of the association between disturbed sleep and depression was 0.11 (95% CI, 0.06-0.15; P < .001; n = 14 067; I2 = 50.8%), and the pooled odds ratio of depression in those with vs without disturbed sleep was 1.50 (95% CI, 1.13-2.00; P = .005; n = 13 006; I2 = 87.7%). Metaregression and sensitivity analyses showed no evidence that pooled estimates differed across any covariate. Substantial publication bias was found.

CONCLUSIONS AND RELEVANCE

This meta-analysis found a small but statistically significant effect size indicating an association between sleep disruption and depressive symptoms in children and youths. The high prevalence of disturbed sleep implies a large cohort of vulnerable children and youths who could develop depression. Disrupted sleep should be included in multifaceted prevention programs starting in childhood.

Hair Cortisol Concentration as a Biomarker of Sleep Quality and Related Disorders

Cortisol is the end product of the hypothalamic-pituitary-adrenal (HPA) axis, and its production is increased mainly in stressful situations or in chronic disorders accompanied by stress enhancement. Altered cortisol concentrations have been reported in a number of neuropsychiatric diseases and sleep disorders. Cortisol concentrations have been measured using several methods, and in several matrixes, such as blood, saliva, and urine. However, lately, hair cortisol, for several reasons, has emerged as a promising biomarker of long-term retrospective HPA activation. Several experimental approaches for cortisol measurement with the corresponding concentration reference ranges and a summary of findings from scientific literature on this field are presented. There is evidence of a close relationship between HPA functional alteration and the development of neuropsychiatric disorders. Sleep disorders are the most common manifestation in several neuropsychiatric conditions, and have also been associated to cortisol alterations in both adults and children. Many studies indicate that hair cortisol constitutes a valuable tool for further contributing to existing data on salivary, plasma, or urinary cortisol concentrations in patients with sleep disorders.

The Associations Between Sleep and Externalizing and Internalizing Problems in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: Empirical Findings, Clinical Implications, and Future Research Directions

Sleep problems are common in youth with attention-deficit/hyperactivity disorder (ADHD). Externalizing and internalizing problems contribute to dysfunction in youth with ADHD and are amplified by disrupted sleep. This objective of this article is to synthesize empirical studies that examined the associations between sleep and internalizing or externalizing problems in individuals with ADHD. The main findings are that sleep problems precede, predict, and significantly contribute to the manifestation of internalizing and externalizing behavior problems among children and adolescents with ADHD. Clinicians should assess sleep and integrate sleep interventions into the management of youth with ADHD.

Evidence Base Update on Assessing Sleep in Youth

BACKGROUND

Sleep is vital to youth well-being and when it becomes disturbed - whether due to environmental or individual factors - mental and physical health suffer. Sleep problems can also be a symptom of underlying mental health disorders. Assessing different components of sleep, including quality and hygiene, can be useful both for identifying mental health problems and for measuring changes in well-being over time. However, there are dozens of sleep-related measures for youth and it can be difficult to determine which to select for a specific research or clinical purpose. The goal of this review was to identify sleep-related measures for clinical and/or research use in youth mental health settings, and to update the evidence base on this topic.

METHOD

We generated a list of candidate measures based on other reviews and searched in PubMed and PsycINFO using the terms "sleep" AND (measure OR assessment OR questionnaire) AND (psychometric OR reliability OR validity). Search results were limited to studies about children and adolescents (aged 2-17) published in English. Additional criteria for inclusion were that there had to be at least three publications reporting on the measure psychometrics in community or mental health populations. Sleep measures meeting these criteria were evaluated using the criteria set by De Los Reyes and Langer (2018).

RESULTS

Twenty-six measures, across four domains of sleep - insomnia, sleep hygiene, sleepiness, sleep quality - met inclusion criteria. Each measure had at least adequate clinical utility. No measure(s) emerged as superior across psychometric domains.

CONCLUSION

Clinicians and researchers must evaluate sleep measures for each use case, as the intended purpose will dictate which measure is best. Future research is necessary to evaluate measure performance in transdiagnostic mental health populations, including youth with serious mental illness.

Telemedicine in Pediatric Sleep

Prior to the COVID-19 pandemic, few pediatric sleep medicine clinicians routinely engaged in telemedicine visits because thorough examinations were difficult to perform; there was lack of consistent reimbursement; and many clinicians were busy with their in-office practices. This article reviews how telemedicine has been explored in pediatric sleep medicine prior to the pandemic, current applications of telemedicine, challenges, and reimagining pediatric sleep within the realm of telemedicine.

Do insomnia and/or sleep disturbances predict the onset, relapse or worsening of depression in community and clinical samples of children and youth? Protocol for a systematic review and meta-analysis

INTRODUCTION

Disturbed sleep represents a potentially important modifiable risk factor for the development of depression in children and youth. This protocol for a systematic review proposes to investigate whether insomnia and/or sleep disturbances predict child and youth depression in community and clinical-based samples.

METHODS AND ANALYSIS

The protocol adheres to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. English-written, longitudinal studies that quantitatively estimated the prediction of depression by insomnia and/or sleep disturbances in individuals 5-24 years of age will be included. EMBASE, MEDLINE, PsychINFO, Scopus and Web of Science and grey literature will be searched from 1980 to the present. For the selection of studies, two reviewers will be involved. Data extraction will be conducted by one author and checked independently by a second author. Risk of bias will be appraised using the Research Triangle Institute Item Bank tool. Heterogeneity will be measured using the I2 statistics. Meta-analysis will be carried out if ≥3 results are available and if outcome measures can be pooled. The choice between a random-effect or fixed-effect model will be based both on the I2 statistics and the participant and study characteristics of the combined studies. Results of the meta-analyses will be summarised by a forest plot. Analyses will be performed in subgroups stratified by key variables defined depending on the amount and type of information retrieved.A narrative synthesis will be conducted in place of the meta-analysis should the pooling of data not be possible. Quality of evidence will be rated using the Grading of Recommendations Assessment, Development and Evaluation guidelines.As this is a protocol for systematic review and meta-analysis of published data, ethics review and approval are not required. The findings will be published in a peer-reviewed journal and disseminated at scientific conferences and in patient advocacy organisations.

PROSPERO REGISTRATION NUMBER

CRD42019136729.

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.

A transdiagnostic sleep and circadian intervention for adolescents: six-month follow-up of a randomized controlled trial

BACKGROUND

This study examined the 6-month follow-up outcomes of the Transdiagnostic Sleep and Circadian Intervention (TranS-C), compared to Psychoeducation about sleep and health (PE).

METHODS

Adolescents (mean [SD] = 14.77 [1.84] years) with eveningness chronotype and "at-risk" in at least one of five health domains were randomized to receive TranS-C (n = 89) or PE (n = 87) at a university-based clinic. Primary outcomes were average weeknight total sleep time and bedtime calculated from sleep diary, a questionnaire measure of circadian preference, and composite risks in five health domains. Secondary outcomes were selected sleep diary indices, sleepiness, and self- and parent-reported sleep, parent-reported risks in five health domains.

RESULTS

Relative to PE, TranS-C showed treatment effects through 6-month follow-up on only one primary outcome; namely eveningness circadian preference. TranS-C also showed treatment effects on two sleep and circadian secondary outcomes, including the Pittsburgh Sleep Quality Index and sleep-diary measured weeknight-weekend discrepancy in wakeup time. TranS-C did not show treatment effects on self-report or parent-report composite risks in five health domains. PE showed benefit, relative to TranS-C, from posttreatment to 6-month follow-up for reducing parent-reported behavioral health risk (secondary outcome).

CONCLUSIONS

In at-risk adolescents, the evidence supports the TranS-C treatment effects over six months on improving sleep and circadian functioning on selected outcomes but not on reducing risk in five health domains.

Sleep Disorders in Adolescents

Chronic sleep deprivation is a common, treatable condition among adolescents. Growing literature supports a myriad consequences that impact overall health, behavior, mood, and academic performance in this vulnerable age group during a time when there are rapid changes in physical development and emotional regulation. This article reviews the epidemiology and health effects of sleep deprivation in adolescents as well as common disorders leading to sleep loss and evidence to support treatment. Although a variety of important sleep disorders may disrupt quality of sleep in adolescents, such as obstructive sleep apnea, restless leg syndrome, and narcolepsy, this article will focus on common disorders that affect the quantity of sleep, such as poor sleep hygiene, circadian rhythm disorders, and insomnia.

Digital Cognitive Behavioral Therapy for Insomnia for Adolescents With Mental Health Problems: Feasibility Open Trial

BACKGROUND

Insomnia in adolescents is common, persistent, and associated with poor mental health including anxiety and depression. Insomnia in adolescents attending child mental health services is seldom directly treated, and the effects of digital cognitive behavioral therapy (CBT) for insomnia (CBTi) on the mental health of adolescents with significant mental health problems are unknown.

OBJECTIVE

This open study aimed to assess the feasibility of adding supported Web-based CBT for insomnia to the usual care of young people aged 14 to 17 years attending specialist child and adolescent mental health services (CAMHS).

METHODS

A total of 39 adolescents with insomnia aged 14 to 17 years attending specialist CAMHS were assessed and offered digital CBTi. The digital intervention was Sleepio, an evidence-based, self-directed, fully automated CBTi that has proven effective in multiple randomized controlled trials with adults. Self-report assessments of sleep (Sleep Condition Indicator [SCI], Insomnia Severity Scale, and Web- or app-based sleep diaries), anxiety (Revised Child Anxiety and Depression Scale [RCADS]), and depression (Mood and Feelings Questionnaire [MFQ]) were completed at baseline and post intervention. Postuse interviews assessed satisfaction with digital CBTi.

RESULTS

Average baseline sleep efficiency was very poor (53%), with participants spending an average of 9.6 hours in bed but only 5.1 hours asleep. All participants scored less than 17 on the SCI, with 92% (36/39) participants scoring 15 or greater on the Insomnia Severity Scale, suggesting clinical insomnia. Of the 39 participants, 36 (92%) scored 27 or greater on the MFQ for major depression and 20 (51%) had clinically elevated symptoms of anxiety. The majority of participants (38/49, 78%) were not having any treatment for their insomnia, with the remaining 25% (12/49) receiving medication. Sleepio was acceptable, with 77% (30/39) of the participants activating their account and 54% (21/39) completing the program. Satisfaction was high, with 84% (16/19) of the participants finding Sleepio helpful, 95% (18/19) indicating that they would recommend it to a friend, and 37% (7/19) expressing a definite preference for a digital intervention. Statistically significant pre-post improvements were found in weekly diaries of sleep efficiency (P=.005) and sleep quality (P=.001) and on measures of sleep (SCI: P=.001 and Insomnia Severity Index: P=.001), low mood (MFQ: P=.03), and anxiety (RCADS: P=.005).

CONCLUSIONS

Our study has a number of methodological limitations, particularly the small sample size, absence of a comparison group and no follow-up assessment. Nonetheless, our findings are encouraging and suggest that digital CBTi for young people with mental health problems might offer an acceptable and an effective way to improve both sleep and mental health.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/11324.