A motivational school-based intervention for adolescent sleep problems

Abstract

Objective

The current study aimed to develop and evaluate a motivational school-based intervention for adolescent sleep problems.

Methods

The intervention was implemented in three co-educational secondary schools in Adelaide, South Australia. Two year-11 Psychology classes from each school participated, with one as the intervention class (N = 53) and one as the control class (N = 51). Students in the intervention classes attended four 50-min sleep education classes, held once per week. The lessons were modified from those of Moseley and Gradisar [23] to incorporate a motivational interviewing framework. Students completed an online questionnaire battery measuring school day and weekend sleep parameters, daytime sleepiness, and depression at pre- and post-program and follow-up, and completed motivation to change questionnaires during the program.

Results

Students in the intervention group significantly increased their knowledge about sleep relative to the control group (p = 0.001). During the intervention, students’ motivation to regularize their out-of-bed times improved (p = 0.03), and there was a trend towards improved motivation to increase average total sleep time (p = 0.11). But despite improvements in sleep and daytime functioning for adolescents in the program group (p < 0.05), these changes were not significantly different from the control group (all p > 0.05).

Conclusions

School-based interventions are promising for educating adolescents about sleep. Future programs should translate increased motivation into long-term behavioral change. The identification of barriers and support to assist this change is recommended.

Introduction

It is well known that developmental changes to sleep patterns occur as children enter adolescence. Children move from getting an average of 9.6 h sleep per night at age 11 years, to an average of 8.1 h sleep at age 16 years [1]. But more recent data suggest adolescents across the world are getting even less sleep, with an average of 7.6 h sleep per night most commonly reported [2], [3]. This decreased nocturnal sleep is associated with increasingly delayed bedtimes, yet fixed school morning wake-up times [4]. Adolescents then have a tendency to sleep-in on weekend mornings in order to “catch up” on this insufficient sleep [4], [5]. This reduces adolescents’ weekend sleep pressure, making it more difficult for them to fall asleep on subsequent school nights, producing an ongoing cycle [6]. For some of these adolescents, this cycle maintains a delayed sleep timing with impaired daytime functioning (e.g., daytime sleepiness, depressed mood) and, in extreme cases, significantly impairs their quality of life leading to a diagnosis of Delayed Sleep Phase Disorder (DSPD) [7], [8], [9].

Sleep problems in adolescence, including those involving delayed sleep timing, have both short-term and long-term consequences. Short term consequences include daytime sleepiness, poor concentration, poor academic performance, impaired working memory, and behavioral problems [10], [11], [12]. Long-term consequences include an increased risk of developing comorbid adult-onset anxiety disorders [13] and potentially a decreased chance of successful transition from high school to tertiary studies or employment [14]. In addition, a recent study comparing adolescent suicide completers to a control group found higher rates of sleep disturbance in the suicide completers, even after controlling for depression [15]. Thus, it is important that adolescents experiencing sleep problems receive appropriate intervention.

Group cognitive-behavior therapy for adolescent sleep problems has shown promise, with significant improvements in sleep latency, number of awakenings, sleep efficiency, and sleep quality, despite less than half of the adolescents attending at least 67% of sessions [16]. But many adolescents who could benefit from treatment do not receive it, as sleep problems are rarely screened for in general healthcare settings [17], not to mention that adolescents engaging in treatment programs tend to have low motivation and treatment adherence, fail to attend sessions, or drop out all together [16]. Taken together, this means that many adolescents who could benefit from intervention do not receive or engage in it.

Given the widespread nature of these problems and the motivational issues affecting attendance at clinical settings, the school classroom could be considered as an alternative arena for sleep intervention. This has been attempted by several groups of researchers [18], [19], [20], [21], [22]. To date, the research has consisted of small sample sizes, lack of control group, and lack of follow-up data. Results have been mixed, with some studies showing improved knowledge about sleep, despite having no data about changes in sleep habits or behavior [18], [19]; another study found no change in sleep from pre- to post-treatment [20]; yet some have found changes in sleep from pre- to post-treatment, although small sample sizes were used and they lacked a control group and follow-up data [21], [22].

A recent study by Moseley and Gradisar [23] attempted to overcome the abovementioned limitations by implementing a school-based sleep education program with 81 students. Adolescents in the intervention group improved their sleep knowledge; however, compared to the control group, there were no significant improvements in their sleep. Nonetheless, a subsample of 36 students (classified as having delayed sleep timing) had a significantly smaller discrepancy between school day and weekend out-of-bed times at post-program compared to the control group. Overall, however, feedback suggested that students were not very motivated to reduce their weekend sleep-ins. Based on the transtheoretical model of change which describes successive levels of motivation to change one’s behavior (i.e., Stage 1: pre-contemplation – not considering change; Stage 2: contemplation – ambivalent about changing; Stage 3: determination – determined to change; Stage 4: action – changing behavior; Stage 5: maintenance – maintaining behavior change) [24], many students would have been in the “pre-contemplation stage,” despite a significant number of students reporting poor sleep.

Motivational Interviewing is a client-centered, goal-directed counselling framework that aims to enhance intrinsic motivation by exploring and resolving ambivalence [25]. Considering Moseley and Gradisar’s [23] findings that students improved in their knowledge about sleep but remained ambivalent about reducing their weekend sleep-ins, the principles of Motivational Interviewing [25] could be successfully applied to school-based sleep interventions to help students improve their sleep habits. Thus, the current study aimed to evaluate a motivational school-based sleep intervention for adolescent sleep problems.