CBT-I Cannot Rest Until the Sleepy Teen Can

Sleeplessness occurs across the lifespan, yet a search of the literature will show a U-shaped pattern for the number of published sleep intervention studies across the lifespan. There are a sufficient number of studies dealing with the treatment of sleep problems in young children, and insomnia in adults to warrant systematic reviews,^1–4 meta-analyses,^5–8 and practice parameters,^9,10 However, there are considerably fewer studies of sleeplessness in the adolescent years, when physiological development is still underway at a rapid pace, and there are a range of emotions and behaviors associated with relationships, school, extracurricular activities, and employment that can disrupt sleep.

Studies of insomnia typically include an exclusion criterion of being aged < 18 years of age. However, studies also suggest that up to 1 in 3 adolescents meet DSM-IV criteria for insomnia.^11–13 Weeknight sleep during adolescence appears to be relatively shorter than that experienced in childhood.¹⁴ Consequently, it is no surprise there are millions of sleepy, moody, irritable teenagers worldwide who need help.^15,16 While the latest meta-analyses for CBT-I for adult insomnia include 14 studies,⁵ there has been a dearth of controlled trials of CBT-I for adolescents. In this issue of SLEEP, de Bruin and colleagues¹⁷ have broken the silence in the scientific literature by sharing the findings of the very first randomized controlled trial of CBT-I for adolescents diagnosed with insomnia. Being cognizant that adolescents can lack the motivation to seek and persist with treatment,^18,19 their randomized controlled trial of CBT-I was adapted to both internet and group formats and compared to a waitlist control.

De Bruin and colleagues objectively (actigraphy) and subjectively (sleep logs, questionnaires) measured the sleep of 116 teenagers (mean age = 15.6 years) before and after 6 weeks of CBT-I, which included: psychoeducation, sleep hygiene, sleep restriction therapy, stimulus control, cognitive therapy, and relaxation techniques. Group CBT-I consisted of weekly 1.5-hour sessions with 6 to 8 teenagers, facilitated by two therapists. Internet CBT-I was conducted via the researchers' website where teenagers logged on each week and were primarily self-guided through a series of exercises, movie clips, questionnaires, automated feedback, and tailored bedtime recommendations. Compared to adolescents in the control group, both internet and group therapy were found to produce comparable posttreatment improvements in sleep efficiency, sleep onset latency, wake after sleep onset, and daytime functioning. Importantly, these moderate-to-large improvements were maintained at a 2-month follow-up, and were matched with clinically significant improvements.

Given the distinct lack of randomized controlled trials for this population, the report by De Bruin and colleagues¹⁷ is seminal. However it is also just the beginning: CBT-I for adolescent insomnia needs independent replication so we can be more confident about its efficacy. Indeed, the volume of work performed with CBT-I for adults can guide future work into CBT-I for adolescents to answer a host of questions. Which CBT-I treatment components are most effective in adolescents? What factors predict better treatment outcomes in adolescents? Is internet/group CBT-I for adolescents cost effective? Aside from self-reported chronic sleep reduction, does CBT-I improve school attendance, academic performance, emotional regulation, and other aspects of daytime performance? Can CBT-I be effective for adolescents with insomnia and comorbid mental/medical conditions? Does CBT-I perform better than other treatments? The list of research questions is extensive and highlights that our field has only begun to evaluate treatment for adolescent insomnia, which may or may not present and respond to treatment like adult insomnia. We currently lag behind many other adolescent physical and mental health fields (e.g., antisocial behavior,²⁰ anxiety disorders,²¹ chronic pain,²² depression,²³ obesity,²⁴ sexual abuse,²⁵ sexual offending,²⁶ suicide behavior,²⁷ traumatic stress²⁸). This is an opportunity for the sleep field to address a widespread sleep problem in a vulnerable population.

Despite the therapeutic benefits from both active treatment conditions, when given a choice in the study by De Bruin and colleagues,¹⁷ almost all adolescents elected to receive internet treatment rather than group therapy. This affirms adolescents' affinity for technological platforms to engage in treatment, and opens possibilities for CBT-I reaching out to adolescents in rural and remote areas where specialized treatment may be lacking. In concert with evaluations of 1-on-1 face-to-face CBT-I²⁹ and school-based sleep interventions,³⁰ it may be possible to develop stepped-care guidelines for the treatment of adolescent insomnia.³¹ In doing so, we may be able to improve the uptake, cost-effectiveness and outcomes of treatment for insomnia in our youth, which will likely lead to innovations in our clinical practice and public health initiatives for this neglected sleepy sub-population.

To conclude, possibly the greatest value to come from the study by De Bruin and colleagues may be that it increases our awareness that, for decades, our field has overlooked those sleepless in their second decade of life. In 2003, a question was asked whether the sleep research field could rest yet, when it came to the ability of CBT-I to deal with insomnia.³² The work of de Bruin et al. would suggest it is not too late for early intervention for adult insomnia—but that is another question for our field to focus on and answer. For now we eagerly await the findings from additional randomized controlled trials for sleepy adolescents already underway³³ and hope for many more designed to help this vulnerable population.

CITATION

Gradisar M, Richardson C. CBT-I cannot rest until the sleepy teen can. SLEEP 2015;38(12):1841–1842.

DISCLOSURE STATEMENT

Michael Gradisar has performed workshops for the Australian Psychological Society, is a shareholder in ResMed, and received partial industry funding from Re-Timer Pty Ltd. Cele Richardson has indicated no financial interests.