Original ArticleA motivational school-based intervention for adolescent sleep problems
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.
Section snippets
Participants
Participants were 104 year-11 students from three co-educational secondary schools in the Adelaide metropolitan area (62 females, 42 males, mean age = 16.2 ± 0.4 years). Two Psychology classes from each school participated, with one as the intervention group (N = 53) and one as the control group (N = 51). The three schools were matched on socio-economic status based on rankings of the percentage of students with school cards (i.e., a government scheme providing financial assistance towards educational
Baseline sleep and daytime functioning measures
At baseline, 37.9% of the sample reported difficulty initiating sleep (SOL > 30 min), 59.2% reported insufficient sleep on school nights (<8 h), and 74.8% reported discrepant school-weekend out-of-bed times (>2 h). Means and standard deviations (SDs) for all variables are presented in Table 1. T-tests revealed a significant difference between groups on depression, t(101) = −2.81; p < 0.01, but there were no significant differences between groups for the target sleep parameters, daytime sleepiness, or
Discussion
The school-based sleep intervention evaluated in the present study aimed to provide adolescents with information about sleep and to motivate them to make changes in several target sleep behaviors. Consistent with previous studies, improvements were seen in students’ sleep knowledge relative to a control group [19], [23]. Furthermore, students’ motivation to regularize their out-of-bed times increased during the program, and students with delayed sleep timing (DST) became more motivated to
Conclusion
Consistent with the results of Moseley and Gradisar [23], the present study demonstrated that an increase in sleep-related knowledge does not always translate into changes in behavior that are maintained over time. While school-based interventions can improve students’ motivation to change sleep-related behaviors, and students are happy to engage with homework-based behavioral experiments, future studies should focus on motivating students to maintain these changes over time. This could include
Financial support
Faculty of Social Sciences, Flinders University
Conflicts of Interest
The ICMJE Uniform Disclosure Form for Potential Conflicts of Interest associated with this article can be viewed by clicking on the following link: doi:10.1016/j.sleep.2010.06.008.
Acknowledgements
The authors wish to thank Mr Ben Maddock for assistance with the online administration of questionnaires, the principals of Concordia College, St John’s Grammar School, and Unley High School for approving the implementation of the program in their schools, teachers Ms Kathy Ayliffe, Mr Graham Clark, Ms Ruth Eckert, Ms Nikki Krieg, and Ms Daniela Wells for accommodating the program in their courses, and all students who participated in the study.
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2022, Sleep Medicine ReviewsCitation Excerpt :Such SEP could also be administered to adolescents as part of institutional residential facility (e.g., boarding schools, treatment center, juvenile detention center) programming. Employing a motivational framework within SEP increased knowledge and motivation, but not sleep or daytime sleepiness relative to a control intervention [82]. Efforts to supplement SEP with one weekend of wearable, short-wavelength LT did not bolster treatment effects on sleep knowledge, sleep outcomes, or motivation to engage in treatment components relative to SEP with parental involvement, SEP with parental involvement and LT, and class-as-usual; although a low dose of the adjunctive interventions may have contributed to the lack of group differences [111].