A cognitive-behavioral and mindfulness-based group sleep intervention improves behavior problems in at-risk adolescents by improving perceived sleep quality
Introduction
Many adolescents obtain insufficient and/or poor quality sleep, which is increasingly regarded as an important public health problem (American Medical Association, 2010). Adolescents are thought to optimally require approximately nine hours of sleep per night (Fuligni, Arruda, Krull, & Gonzales, 2017). However, a recent meta-analysis found that 53% of adolescents obtain less than 8 h of sleep on school nights, and 36% report difficulty falling asleep (Gradisar, Gardner, & Dohnt, 2011). Physiological maturation processes (Colrain & Baker, 2011) and social/cultural factors (Bartel et al., 2015, Maume, 2013) interact in adolescence so that reduced sleep propensity in the late evening becomes permissive of continued waking activities and delayed bedtimes (BT). This delay in sleep onset results in sleep restriction, because school starts early in the morning. Further, sleep has reduced restorative value, because recovery sleep tends to occur at an inappropriate circadian phase (Carskadon, 2011). Adolescents are also vulnerable to the same processes that cause insomnia in adults, such as susceptibility to hyperarousal (Alfano et al., 2010, Blake et al., 2017a, Riemann et al., 2010).
Sleep disturbance is an important contributor to increased vulnerability and risk among young people (Harvey, 2015). There is emerging evidence that adolescent sleep disturbance may precipitate and maintain many emotional and behavioral problems (Dahl & Harvey, 2007). Indeed, recent reviews have concluded that sleep problems, particularly wakefulness in bed (e.g., prolonged sleep onset latency [SOL] and poor sleep efficiency [SE]), precede the development of anxiety and depression in adolescence more than the reverse (Lovato and Gradisar, 2014, McMakin and Alfano, 2015). However, in comparison to internalizing symptoms, relatively few studies have examined the role of sleep disturbance in adolescent behavior problems (Becker, Langberg, & Byars, 2015).
Cross-sectional, experimental, naturalistic, and longitudinal studies have consistently shown that adolescent sleep disturbance is associated with social problems, attention problems, and aggressive behaviors, including school non attendance (Shochat, Cohen-Zion, & Tzischinsky, 2014), social withdrawal (Carney, Edinger, Meyer, Lindman, & Istre, 2006), loneliness (Mahon, 1994), difficulties in peer relationships (Roberts et al., 2002, Sarchiapone et al., 2014), inattentive behaviors (Gregory & O'Connor, 2002; O'Callaghan et al., 2010), academic problems (Shochat et al., 2014), oppositionality (Beebe et al., 2008), and hostile behaviors (Gregory and O'Connor, 2002, Gregory et al., 2008, Ireland and Culpin, 2006), which may mimic Attention Deficit Hyperactivity Disorder (ADHD) and Conduct Disorder (Dahl, 1996). However, further high quality longitudinal and treatment outcome studies are needed that examine the prospective and causal associations between poor sleep and behavior problems in adolescents (Becker et al., 2015, Dewald et al., 2010, Shochat et al., 2014).
Adolescents with concomitant sleep and internalizing problems may be particularly vulnerable to behavior problems. Young people with anxiety disorders exhibit exaggerated hypoconnectivity between the prefrontal cortex (PFC) and amygdala (Hamm et al., 2014), and adolescents with depression show elevated activity in extended medial networks regions, including the anterior cingulate cortex, ventromedial and orbitofrontal cortices, and amygdala (Kerestes, Davey, Stephanou, Whittle, & Harrison, 2014). Adolescents with internalizing symptoms are also prone to cognitive biases, including interpretational biases, judgment biases, negative attributional styles, and hypervigilance for threat (Garber and Weersing, 2010, Price et al., 2016). These physiologic and cognitive/emotional vulnerabilities are likely to further compromise their behavior regulation, especially under conditions of sleep deprivation. In support of this, children and adolescents with anxiety and depressive disorders have been shown to use maladaptive ways of regulating their behavior, including avoidance, excessive reassurance seeking, and less effective problem-solving (Thompson et al., 2010, Garber and Weersing, 2010, Thompson et al., 2010, Tsypes et al., 2013, Weems et al., 2000). Furthermore, adolescents with internalizing problems may have particular difficulties adhering to good sleep hygiene behaviors (Blake et al., 2017a), as they may spend more time in their bedroom and delay sleep as a means of avoiding disorder-specific stressors and cognitions.
These findings suggest that quality sleep in childhood and adolescence is critical for optimizing emotional health, social functioning, and cognitive development. Moreover, early treatment programs for sleep problems might reduce the risk for developing internalizing disorders and behavior problems and can be considered a helpful general preventive strategy. Sleep disturbance in adolescents can be treated using a range of approaches. Recent reviews have suggested that while school-based sleep education programs are effective for improving students’ knowledge about sleep and insomnia, they are less effective for improving sleep behavior or mental health (Blunden and Rigney, 2015, Blunden et al., 2012, Gruber, 2017). This is consistent with research showing that targeted interventions are more effective than universal interventions in preventing child and adolescent mental health problems (Rohde, 2015), and that simple sleep hygiene instruction does not guarantee positive outcomes in adults (Irish, Kline, Gunn, Buysse, & Hall, 2015).
There is emerging evidence that adolescent sleep problems can be treated more effectively using cognitive-behavioral therapies. Cognitive-behavioral therapy for insomnia (CBT-I) is recommended as a front-line treatment for adult insomnia (Qaseem, Kansagara, Forciea, Cooke, & Denberg, 2016), based on evidence from multiple systematic reviews and meta-analyses that the intervention improves sleep and mental health in adults, usually with medium-large effect sizes (Ballesio et al., 2017, Taylor and Pruiksma, 2014, Trauer et al., 2015, Van Straten et al., 2017). CBT-I involves behavioral techniques such as sleep hygiene instruction, stimulus control, sleep restriction therapy, and relaxation training, but also addresses unhelpful beliefs and attitudes about sleep (for a review, see Edinger & Means, 2005). There is also emerging evidence that sleep problems can be treated successfully using protocols that include a mindfulness component (for a meta-analytic review, see Gong et al., 2016). Mindfulness meditation is especially indicated for sleep-related problems because it aims to reduce the hyperarousal and negative emotional states that are frequently reported by individuals with sleep problems (Harvey, 2002, Riemann et al., 2010).
Research on adolescent cognitive-behavioral and mindfulness-based sleep interventions is not as developed as the adult literature. A recent systematic review and meta-analysis found that only nine trials (n = 357) have examined the efficacy of face-to-face cognitive-behavioral sleep interventions among adolescents with self-identified sleep problems or a diagnosis of a sleep disorder (mean age = 14.97 years, range 11–20 years; Blake, Sheeber, Youssef, Raniti, & Allen, 2017b). Two of the studies evaluated “manualized” CBT-I, whereas the other interventions included added treatment components (e.g., mindfulness, anxiety/depression specific modules). The results showed that the sleep interventions produced marked and statistically significant improvements in objective and self-reported indices of sleep, daytime sleepiness, anxiety, and depression at post-intervention time points. Moreover, gains were generally maintained over time. As with adults, improvements tended to be stronger for wakefulness in bed variables (SOL and SE) compared to sleep duration variables, and self-reported sleep variables compared to objective sleep variables (Trauer et al., 2015). However, the trials included in the meta-analysis were limited in several ways, including small sample sizes, lack of control groups, wait-list control groups, high attrition rates, low generalizability, lack of follow-ups, short follow-ups, failure to differentiate between weekday and weekend sleep, and/or reliance on self-reported measures of sleep. Therefore, high quality, large-scale controlled treatment outcome studies are needed to confirm the findings; in particular, studies are needed that comprehensively assess sleep and functional outcomes. No previous randomized controlled trials (RCTs) have examined the effects of a cognitive-behavioral sleep intervention on adolescent behavior problems, so we know relatively little about these outcomes. Therefore, secondary analyses of non-primary outcomes may be beneficial.
The SENSE Study is an RCT investigating whether a 7-week, cognitive-behavioral and mindfulness-based group sleep intervention can prevent the emergence of Major Depressive Disorder (MDD) at 2-year follow-up among a group of adolescents (aged 12–17) who were experiencing high levels of sleep problems and anxiety symptoms (Waloszek et al., 2015). Strengths of the SENSE study are the large sample size, the well-defined manual-driven treatment consisting of components demonstrated to improve sleep in prior research, the time- and format-equated active control ‘study skills’ condition, and the use of both self-reported and objective measures of sleep duration and quality. We have previously reported the postintervention effects of the intervention on sleep and internalizing symptoms (Blake et al., 2017a, Blake et al., 2016). The results showed that the sleep intervention condition (“Sleep SENSE”) was associated with significantly greater improvements in actigraphy-measured SOL, sleep-diary measured SE, perceived sleep quality, daytime sleepiness, and anxiety compared to the active control condition (“Study SENSE”), with small to medium effect sizes. The aim of the present study was to examine the effects of the intervention on behavior problems at postintervention. We predicted that the Sleep SENSE intervention would improve social problems, attention problems, and aggressive behaviors in adolescents who were experiencing high levels of sleep problems and anxiety symptoms, and that these improvements would be specifically mediated by the measured improvements in objective and self-reported sleep that resulted from the interventions.
Section snippets
Methods
The full methods of the SENSE Study were reported in Waloszek et al., 2015, Blake et al., 2016, and Blake et al. (2017a). Here, we focus on the methods relevant to the present analyses.
Demographic and descriptive statistics
One hundred and twenty-three participants began the interventions (female = 60%; mean age = 14.48, standard deviation = 0.95, range 12.04–16.31 years), with 60 in the Sleep SENSE condition and 63 in the Study SENSE condition. Full demographic and descriptive statistics for the sleep and anxiety variables were previously reported in Blake et al. (2016) and Blake et al. (2017a). Consistent with the inclusion criteria, the intervention sample was characterized by short sleep duration, wakefulness
Discussion
This study provides evidence, using a methodologically rigorous design, that a cognitive-behavioral and mindfulness-based group sleep intervention improved behavior problems (social problems, attention problems, and aggressive behaviors) in at-risk adolescents by improving perceived sleep quality on school nights. There was no evidence of the reverse association.
These findings suggest that improvements in perceived sleep quality may change adolescents' behaviors in ways that increase the
Conclusion
This study provides evidence, using a methodologically rigorous design, that a cognitive-behavioral and mindfulness-based group sleep intervention improved behavior problems (social problems, attention problems, and aggressive behaviors) in at-risk adolescents by improving perceived sleep quality on school nights. These findings suggest that cognitive-behavioral and mindfulness-based sleep interventions could be directed towards adolescents with vulnerability towards behavior problems.
Institution where work was performed
The University of Melbourne.
Funding
Australian National Health and Medical Research Council Grant (APP1027076).
Conflicts of interest
There are no conflicts of interest to disclose.
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2022, Journal of Applied Developmental PsychologyCitation Excerpt :Adolescents' sleep development involves drastic changes, increasing the risk of persistent sleeping difficulties and mental health problems (Poitras et al., 2016; Orchard et al., 2020). Yet, there are evidence- and theory-based interventions available to improve adolescent sleep, with potential long-term mental health benefits (Blake Snoep et al., 2017; Hendricks, & C. M., Grodin, L. K., & Slifer, K. J., 2014). General guidelines indicate cognitive–behavioral therapy for insomnia as the first-line treatment (Mitchell, Gehrman, Perlis, & Umscheid, 2012), but interventions for adolescents might also benefit from identifying the manifold developmental and cascading mechanisms that relay the effects of early maternal psychopathology on children's sleep.