Mind-Body Integrative Health (MBIH) Interventions for Sleep among Adolescents: A Scoping Review of Implementation, Participation and Outcomes

Abstract

Adolescents get insufficient sleep, adversely affecting health. Mind-body integrative health interventions for adolescents have been shown to reduce stress, a barrier to good sleep. This scoping review aimed to synthesize mind-body integrative health interventions for adolescents, how interventions were implemented, who was reached. A systematic search of four online databases was conducted. Randomized, quasi-experimental, and single-group designs with participants ages 10–24 years were included. Twelve studies covering 10 interventions using mindfulness, qigong, aromatherapy, or yoga were identified. Participants were predominantly female; only one study reported participants’ race or ethnicity (81% non-Hispanic white). Most (n=6) interventions were delivered in groups, and half reported significant improvements in subjective sleep quality. Mindfulness-based stress reduction and mindfulness-based cognitive therapy were the most commonly used modalities, with reported impact on sleep outcomes measured objectively. The two interventions that found statistically significant, moderate improvements in objectively-measured sleep onset latency and sleep efficiency were of higher intensity and used mindfulness. Four interventions were self-directed; participants in these struggled with adherence; significant impacts on sleep were not found. While findings were mixed, stemming in part from the quality of the underlying studies, this review identified several promising features of interventions, including using mindfulness, ensuring sufficient intervention dose, and targeting interventions towards adolescents with poor sleep at baseline (rather than a general population of adolescents). The findings suggests that sleep interventions for adolescents may improve psychological well-being as an intermediate effect, as sleep improvements were observed mostly among participants with poor sleep quality or anxiety symptoms at baseline. This review identified several gaps in the literature. Despite documented racial and ethnic disparities in sleep quality among adolescents, published evidence of mind-body integrative health-based sleep interventions among Black and Latinx adolescents is lacking. None of the studies in this review assessed developmental stage or age differences, despite documented differences in sleep across age groups of adolescents. These two gaps in the evidence should be addressed in future intervention research.

Introduction

Sleep is critical for the health and wellbeing of adolescents, but evidence shows that adolescents do not get sufficient sleep (Kann et al. 2018). Interventions are needed to improve adolescent sleep (Owens et al. 2014). Mind-body integrative health interventions – which include a broad range of approaches -- have been shown to improve sleep quality in adults (Neuendorf et al. 2015), and show promise for improving the physical and mental health of adolescents (McClafferty et al. 2016). But no studies thus far have synthesized what is known about mind-body integrative health interventions to improve sleep among adolescents. This review was undertaken to synthesize the evidence base on such interventions, with the goal of guiding future intervention research to address this public health priority.

Insufficient sleep in adolescence is associated with impaired physical (Chaput et al. 2016) and mental health (Lovato and Gradisar 2014; Wong et al. 2013), increased risk-taking (Short and Weber 2018) including substance use (Nguyen-Louie et al. 2018), poor academic performance (Ahrberg et al. 2012; Okano et al. 2019) and current (Javaheri et al. 2008) and subsequent cardiovascular health risk (Knutson et al. 2007). Research has consistently shown that adolescents get insufficient sleep (Kann et al. 2018), and that this trend has worsened in recent decades (Twenge et al. 2017); reflecting this, Healthy People 2020 includes a goal of increasing the proportion of high school students and adults who get sufficient sleep (Koh et al. 2014). Adolescence, the phase of life between childhood and adolescence that spans ages 10 – 24 years, is defined by biological and social changes that result in unique developmental needs (Sawyer et al. 2018). Within adolescence, there are changes in sleep patterns: older adolescents, compared to younger, get less sleep, particularly on school nights (Gradisar et al. 2011). Adolescents experience changes in their sleep needs, sleep patterns, and sleep behaviors over time due to both neurobiological developmental changes (Colrain and Baker 2011) and social environments and pressures during the transition from childhood to adulthood. Specific social factors impeding sleep for adolescents include a misalignment between adolescent circadian sleep patterns and school schedules, specifically early school times (Adolescent Sleep Working Group 2014) (sometimes referred to as “social jet lag” (Malone et al. 2016)), electronic media (Lund et al. 2021) and social media usage (Alonzo et al. 2020), and mental health issues including anxiety and stress (Owens et al. 2014).

Mind-body integrative health approaches are a diverse group of modalities provided or taught by a trained professional aimed at promoting health by improving the mind’s positive impact on the body, and vice versa (U.S. Department of Health and Human Services.). Mind-body integrative health approaches (Neuendorf et al. 2015), including yoga (Patel et al. 2012), meditation (Goyal et al. 2014), mindfulness (Gong et al. 2016; Rusch et al. 2019), self-hypnosis (Hauri et al. 2007), acupressure (Waits et al. 2018), and aromatherapy (Lillehei et al. 2015), have been shown to improve sleep quality and duration in adults, in part by reducing stress (Goyal et al. 2014; Lau et al. 2018). Mindfulness interventions have been extensively studied among adults, and meta-analyses have shown moderate strength of evidence that they improve sleep quality compared to active controls (Rusch et al. 2019). Systematic reviews examining broad ranges of mind-body integrative health modalities for improving sleep in adults have noted methodological limitations that have impeded comparison of the relative effectiveness of different modalities (Wang et al. 2019; Neuendorf et al. 2015) but have pointed to intervention duration and intensity as a driver of efficacy.

To date, reviews of sleep interventions for adolescents have primarily focused on using cognitive behavioral therapy for insomnia CBT-I (Ma et al. 2018; Åslund et al. 2018), without examining other mind-body integrative health approaches among the broader population of adolescents. Mind-body integrative health approaches are promising because stress has been identified as a barrier to good sleep in adolescents (Hoyt et al. 2018; Bauducco et al. 2016), and mind-body integrative health interventions for adolescents using mindfulness (Caldwell et al. 2010; Sibinga et al. 2013), meditation (Cheng 2016), yoga (Noggle et al. 2012) have been shown to reduce stress. Specifically, mindfulness has been identified as a promising mind-body approach for use with adolescents because it may improve social functioning and non-judgmental attention control, which may in turn affect other outcomes that relate to sleep, such as psychopathology (Dunning et al. 2019).

Current Study

Given the links between adolescent sleep and health, and the evidence that adolescents are not getting sufficient sleep, and that such gaps in sleep needs are worsening over time, improving adolescent sleep is a public health priority. Interventions that are appropriate for adolescents and that show promise for improving sleep given what is known from the evidence base of mind-body integrative approaches for sleep among adults are needed. There is limited evidence on how to implement mind-body integrative health interventions for improving adolescent sleep. A better understanding of how mind-body integrative health interventions could be designed and implemented to improve sleep in adolescents is needed.

To inform the development of such interventions, this scoping review sought to synthesize the mind-body integrative health approaches that have been used to improve sleep outcomes in adolescents; specifically to describe the modalities used, the components of effective interventions (duration, intensity, format, deliverer), the settings in which they are delivered, who was reached by the interventions, what sleep outcomes are assessed and how they are measured, what outcomes were observed, and whether these outcomes differed across subgroups. This review was designed to include a broad range of intervention types and study designs, not only to synthesize what is already known, but also to identify gaps in the published evidence in order to guide potential avenues for future intervention work. The evidence base on mind-body integrative health interventions and sleep in the adolescent population has not yet been synthesized with an eye to guiding future intervention development and testing.

Methods

Based on an initial review of databases and a review of protocol registries, research on mind-body integrative health approaches and sleep in adolescents is nascent. Published literature on mind-body integrative health approaches on adolescent sleep has not yet been synthesized to support any significant claims. This review sought to characterize the modalities and content of the interventions as well as the effects; thus a scoping review is the most appropriate format for synthesizing the research evidence (Arksey and O’Malley 2005). Scoping reviews are of particular use when there is a broad research question, when a body of literature has been shown to be heterogeneous (Khalil et al. 2016) and when recommendations for future research (not practice (Munn et al. 2018) are needed. This scoping review was conducted in accordance with the guidelines of the Joanna Briggs Institute (JBI) for scoping reviews (Peters et al. 2015a; Peters et al. 2015b) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines to summarize findings (Tricco et al. 2018).

The protocol for this scoping review was published with Open Science Framework (doi: 10.17605/OSF.IO/HZKYW; available at https://osf.io/hzkyw). No changes were made to the primary or secondary research questions, methodology, or outcomes since publication of the protocol, or in the brief gap between the execution of the search strategy and the online publication of the scoping review protocol. No data were extracted prior to the online publication of the scoping review protocol.

Eligibility Criteria

A PICOS table, outlining the population, interventions, comparators, outcomes, and settings that would be included and excluded was used to operationalize the research question (Riva et al. 2012; Rios et al. 2010). The PICOS table and search strategies are in Table 4.

TABLE 4 :

Full Search Strategy by Each Database

	Include	Exclude
P – Population (age)	Adolescents ages 10–24 at enrollment or must include age-stratified results	Age <10 or Age >24 Study must include at least half of sample in this age range; must present age-specific (stratified) findings
P – Population (setting, health state)	Non-institutionalized without chronic illness Symptoms of anxiety or depression Include Poor sleep quality Include “Symptoms of insomnia” Include	In institutional setting other than school (hospital, criminal justice) Primary diagnosis of cancer, pain or mental illness Diagnosed sleep disorders (e.g. insomnia), disturbances
I – Intervention (type)	Mind-body integrative health: Aromatherapy, Chiropractic, Yoga, Tai chi/Tai ji, Qi gong, Visual imagery, Hypnosis, Hypnotherapy, Self-hypnosis, Acupressure, Acupuncture, Mindfulness-based stress reduction, Transcendental meditation, Relaxation, Massage therapy/pediatric massage, Meditation, Guided therapy, Reiki, Biofeedback, Progressive muscle relaxation, Feldenkrais, Alexander technique, Pilates, Rolfing, Trager	Psychotherapy that can only be delivered by a specialist (e.g. cognitive behavioral therapy) Medication-based, OTC or prescription (melatonin, homeopathy) Herbal teas Sleep hygiene alone Natural products Motivational interviewing not excluded because it’s a technique
I – Intervention (setting)	Schools Community center Community health center or clinic	Inpatient hospital setting Sleep laboratory Include if assessments are done in sleep laboratory; no intervention activities in sleep lab
C – Comparator	Baseline (pre-intervention measurement if single group pre/post) No sleep intervention (usual care) Sleep hygiene intervention alone Pharmacologic intervention
O – Outcomes	Sleep duration Sleep fragmentation Sleep efficiency (total sleep/time in bed) Sleep disruptions Sleep quality Sleep onset	Sleep Disorder diagnosis only Outcome is sleep behaviors only
S – Setting	Any English speaking country or setting where intervention was delivered in English Intervention delivered in language other than English, but publication published in English	Setting where intervention was delivered in language other than English and publication is in language other than English

PubMed Search

(“Adolescent”[Mesh] OR Adolescen*[tiab] OR Teen*[tiab]) AND (“Mind-Body Therapies”[Mesh] OR “Mindfulness”[Mesh] OR “Therapy, Soft Tissue”[Mesh] OR “Acupuncture Therapy”[Mesh] OR “mind-body therap*”[tiab] OR “Mind body therap*”[tiab] OR Aromatherap*[tiab] OR Chiropract*[tiab] OR Yoga[tiab] OR “Tai chi”[tiab] OR “Tai Ji”[tiab] OR “Qi gong”[tiab] OR “Visual imagery”[tiab] OR Hypnosis[tiab] OR Hypnotherap*[tiab] OR “Self-hypnosis”[tiab] OR Acupressure[tiab] OR Acupuncture[tiab] OR “Mindfulness-based stress reduction”[tiab] OR Mindfulness[tiab] OR “Transcendental meditation”[tiab] OR Relaxation[tiab] OR “Massage therap*”[tiab] OR “Pediatric massage”[tiab] OR Meditation[tiab] OR “Guided therapy”[tiab] OR Reiki[tiab] OR Biofeedback[tiab] OR “Progressive muscle relaxation”[tiab] OR Feldenkrais[tiab] OR “Alexander technique”[tiab] OR Pilates[tiab] OR “osteopathic manipulation*”[tiab] OR “emotional freedom technique tapping”[tiab] OR “EFT tapping”[tiab]) AND (“Sleep duration”[tiab] OR “Sleep fragmentation”[tiab] OR “Sleep efficiency”[tiab] OR “Sleep disruption*”[tiab] OR “Sleep quality”[tiab] OR “Sleep onset”[tiab])

Embase Search

(‘adolescent’/exp OR Adolescen*:ti,ab OR Teen*:ti,ab) AND (‘alternative medicine’/exp OR ‘mindfulness’/exp OR ‘soft tissue therapy’/exp OR ‘acupuncture’/exp OR ‘mind-body therap*’:ti,ab OR ‘Mind body therap*’:ti,ab OR Aromatherap*:ti,ab OR Chiropract*:ti,ab OR Yoga:ti,ab OR ‘Tai chi’:ti,ab OR ‘Tai Ji’:ti,ab OR ‘Qi gong’:ti,ab OR ‘Visual imagery’:ti,ab OR Hypnosis:ti,ab OR Hypnotherap*:ti,ab OR ‘Self-hypnosis’:ti,ab OR Acupressure:ti,ab OR Acupuncture:ti,ab OR ‘Mindfulness-based stress reduction’:ti,ab OR Mindfulness:ti,ab OR ‘Transcendental meditation’:ti,ab OR Relaxation:ti,ab OR ‘Massage therap*’:ti,ab OR Meditation:ti,ab OR ‘Guided therapy’:ti,ab OR Reiki:ti,ab OR Biofeedback:ti,ab OR ‘Progressive muscle relaxation’:ti,ab OR Feldenkrais:ti,ab OR ‘Alexander technique’:ti,ab OR Pilates:ti,ab OR ‘osteopathic manipulation*’:ti,ab OR ‘emotional freedom technique tapping’:ti,ab OR ‘EFT tapping’:ti,ab) AND (‘Sleep duration’:ti,ab OR ‘Sleep fragmentation’:ti,ab OR ‘Sleep efficiency’:ti,ab OR ‘Sleep disruption*’:ti,ab OR ‘Sleep quality’:ti,ab OR ‘Sleep onset’:ti,ab)

CINAHL Search

((MH “Adolescence+”) OR (TI “Adolescen*”) OR (AB “Adolescen*”) OR (TI “Teen*”) OR (AB “Teen*”)) AND ((MH “Alternative Therapies+”) OR (MH “Mindfulness”) OR (MH “Acupuncture+”) OR (TI “mind-body therap*”) OR (AB “mind-body therap*”) OR (TI “mind body therap*”) OR (AB “mind body therap*”) OR (TI “aromatherap*”) OR (AB “aromatherap*”) OR (TI “chiropract*”) OR (AB “chiropract*”) OR (TI “yoga”) OR (AB “yoga”) OR (TI “Tai chi”) OR (AB “Tai chi”) OR (TI “Tai Ji”) OR (AB “Tai Ji”) OR (TI “Qi gong”) OR (AB “Qi gong”) OR (TI “Visual imagery”) OR (AB “Visual imagery”) OR (TI “hypnosis”) OR (AB “hypnosis”) OR (TI “hypnotherap*”) OR (AB “hypnotherap*”) OR (TI “self-hypnosis”) OR (AB “self-hypnosis”) OR (TI “acupressure”) OR (AB “acupressure”) OR (TI “acupuncture”) OR (AB “acupuncture”) OR (TI “mindfulness-based stress reduction”) OR (AB “mindfulness-based stress reduction”) OR (TI “mindfulness”) OR (AB “mindfulness”) OR (TI “transcendental meditation”) OR (AB “transcendental meditation”) OR (TI “relaxation”) OR (AB “relaxation”) OR (TI “massage therap*”) OR (AB “massage therap*”) OR (TI “meditation”) OR (AB “meditation”) OR (TI “guided therapy”) OR (AB “guided therapy”) OR (TI “Reiki”) OR (AB “Reiki”) OR (TI “biofeedback”) OR (AB “biofeedback”) OR (TI “progressive muscle relaxation”) OR (AB “progressive muscle relaxation”) OR (TI “Feldenkrais”) OR (AB “Feldenkrais”) OR (TI “Alexander technique”) OR (AB “Alexander technique”) OR (TI “Pilates”) OR (AB “Pilates”) OR (TI “osteopathic manipulation*”) OR (AB “osteopathic manipulation*”) OR (TI “emotional freedom technique tapping”) OR (AB “emotional freedom technique tapping”) OR (TI “EFT tapping”) OR (AB “EFT tapping”)) AND ((TI “sleep duration”) OR (AB “sleep duration”) OR (TI “sleep fragmentation”) OR (AB “sleep fragmentation”) OR “(TI “sleep efficiency”) OR (AB “sleep efficiency”) OR (TI “sleep disruption*”) OR (AB “sleep disruption*”) OR (TI “sleep quality”) OR (AB “sleep quality”) OR (TI “sleep onset”) OR (AB “sleep onset”))

PsycInfo Search

((TI “Adolescen*”) OR (AB “Adolescen*”) OR (TI “Teen*”) OR (AB “Teen*”)) AND ((DE “Mind Body Therapy”) OR (DE “Mindfulness”) OR (DE “Acupuncture”) OR (TI “mind-body therap*”) OR (AB “mind-body therap*”) OR (TI “mind body therap*”) OR (AB “mind body therap*”) OR (TI “aromatherap*”) OR (AB “aromatherap*”) OR (TI “chiropract*”) OR (AB “chiropract*”) OR (TI “yoga”) OR (AB “yoga”) OR (TI “Tai chi”) OR (AB “Tai chi”) OR (TI “Tai Ji”) OR (AB “Tai Ji”) OR (TI “Qi gong”) OR (AB “Qi gong”) OR (TI “Visual imagery”) OR (AB “Visual imagery”) OR (TI “hypnosis”) OR (AB “hypnosis”) OR (TI “hypnotherap*”) OR (AB “hypnotherap*”) OR (TI “self-hypnosis”) OR (AB “self-hypnosis”) OR (TI “acupressure”) OR (AB “acupressure”) OR (TI “acupuncture”) OR (AB “acupuncture”) OR (TI “mindfulness-based stress reduction”) OR (AB “mindfulness-based stress reduction”) OR (TI “mindfulness”) OR (AB “mindfulness”) OR (TI “transcendental meditation”) OR (AB “transcendental meditation”) OR (TI “relaxation”) OR (AB “relaxation”) OR (TI “massage therap*”) OR (AB “massage therap*”) OR (TI “meditation”) OR (AB “meditation”) OR (TI “guided therapy”) OR (AB “guided therapy”) OR (TI “Reiki”) OR (AB “Reiki”) OR (TI “biofeedback”) OR (AB “biofeedback”) OR (TI “progressive muscle relaxation”) OR (AB “progressive muscle relaxation”) OR (TI “Feldenkrais”) OR (AB “Feldenkrais”) OR (TI “Alexander technique”) OR (AB “Alexander technique”) OR (TI “Pilates”) OR (AB “Pilates”) OR (TI “osteopathic manipulation*”) OR (AB “osteopathic manipulation*”) OR (TI “emotional freedom technique tapping”) OR (AB “emotional freedom technique tapping”) OR (TI “EFT tapping”) OR (AB “EFT tapping”)) AND ((TI “sleep duration”) OR (AB “sleep duration”) OR (TI “sleep fragmentation”) OR (AB “sleep fragmentation”) OR “(TI “sleep efficiency”) OR (AB “sleep efficiency”) OR (TI “sleep disruption*”) OR (AB “sleep disruption*”) OR (TI “sleep quality”) OR (AB “sleep quality”) OR (TI “sleep onset”) OR (AB “sleep onset”))

Types of studies.

The review was broad with regard to study designs, including all studies empirically testing the impact of mind-body integrative health interventions (randomized controlled trials, quasi-experimental designs, pilot studies) that were published in English. The review included single-group studies (those without a control or comparison group), and excluded non-empirical studies (e.g. commentaries). Non-peer reviewed publications such as dissertations were eligible for inclusion in this review, as were studies using qualitative methodologies.

Types of participants.

The review included studies with non-institutionalized, non-chronically ill adolescents in a broad age range, spanning 10 to 24 years of age. This age range (1) includes early pubertal changes and the onset of adulthood, both of which have been most recently used to define adolescence (Sawyer et al. 2018), and (2) relates to a broad range of potential intervention settings including schools and universities. Because this review sought to identify interventions for the general adolescent population, clinical populations were excluded from this review. Studies were excluded if participants had a primary diagnosis of a sleep disorder (including insomnia), substance use disorder, or a chronic illness (i.e., physical or mental health illness). Interventions that included symptoms of depression or anxiety as an inclusion criterion were eligible for this review, but interventions that included a clinical diagnosis of depression or anxiety as an inclusion criterion were not.

Types of interventions.

Interventions were included if they targeted sleep by using a modality that was classified in the National Center for Complimentary and Integrative Health (NCCIH) as mind-body integrative health (U.S. Department of Health and Human Services.), or was classified in the Medical Subject Headings (MeSH) with the term “mind-body integrative health” or “mind-body therapies;” this category includes a broad range of modalities including aromatherapy, breathing exercises (including Qigong [sic]), relaxation therapy, and yoga. Interventions did not need to be specifically designed to target sleep to be included; that is, sleep could have been a secondary outcome. Interventions that were medication-based, used psychotherapy, involved only natural products, or sleep hygiene alone were excluded; as were studies that included cognitive behavioral therapy (CBT) without any mind-body integrative approach as identified through the above MeSH terms or key words, as well as interventions set in inpatient hospitals or sleep laboratories. Because the aim of this review was to describe the format and intensity of mind-body integrative health interventions, studies were not excluded based on intervention intensity.

Types of outcome measures.

This scoping review examined a range of sleep outcomes assessed subjectively and/or objectively. To be included, studies must have reported one or more of these outcomes: sleep duration; sleep fragmentation; sleep efficiency (total hours and minutes of sleep as a proportion of total hours and minutes in bed); sleep disruptions; sleep quality; or sleep onset or sleep onset latency.

Search Strategy

This review encompassed articles published from January 1, 1992 (the year in which the National Institutes of Health created the Office of Alternative Medicine, which today has evolved into NCCIH, to evaluate “promising unconventional medical practices”) (U.S. Department of Health and Human Services.) through June 29, 2020. Using an iterative process, all authors developed the search strategies, which are provided in Table 4. Next, the informationist (JU) searched MEDLINE (PubMed), EMBASE, CINAHL, and PsycInfo (Ovid) on June 29, 2020. We hand-searched references in the selected articles searched to identify additional studies that met the above eligibility criteria.

Study Selection

Covidence (http://covidence.org), a web-based systematic review platform, was used to remove duplicates and to facilitate review, selection, and synthesis. Each title and abstract was reviewed independently by two authors for inclusion and exclusion; authors (SG, NU, RH, JU, JMB) discussed articles with discordant ratings in weekly meetings until consensus was achieved. Next, two authors independently reviewed each full text of any article that met eligibility based on title and abstract scan, again with the same five authors discussing discrepant ratings until consensus was achieved. The PRISMA-ScR flow diagram (Tricco et al. 2018) (Figure 1) summarizes the disposition of all articles identified.

Figure 1.

PRISMA flow diagram for the review detailing database searches, number of abstracts screened and full texts retrieved

Data Extraction and Synthesis

The authors who selected the articles contributed to identifying fields for extraction, which was then programmed into Covidence. Fields extracted included: study design (i.e., numbers of groups, participants, allocation, and follow-up period); participant characteristics (i.e., age, gender, and race/ethnicity); intervention details (i.e., type, duration, mode of delivery [e.g., in-person, online], setting and interventionist); sleep outcomes assessed (i.e., dimension of sleep, whether measured objectively, subjectively, or both); other outcomes assessed and the instruments used; impact of the intervention on sleep outcomes; adherence to intervention activities and data collection; and review of the studies’ limitations. Limitations were subsequently categorized guided by domains of study quality including: study design (number of groups, allocation to groups), outcome assessment and follow-up (how outcomes were assessed, duration of follow-up, subgroup analyses), quality of intervention implementation (intervention participation, and adherence to research protocol), and participants and external validity. First, three authors (SG, NU, RH) synthesized the same two articles and compared synthesis, until consensus of the authors (SG, NU, RH, JU, JMB) was achieved on extraction methods (i.e., fields to extract, data points to synthesize, level of detail). Then, each article was extracted independently by two authors, and consensus was reached on the data extraction for each article. To supplement the synthesis in Covidence, three authors (SG, NU, RH) developed brief narrative summaries of findings, synthesizing key points for review and discussion by all authors. Synthesis of results included comparing evidence of efficacy or effectiveness across mind-body integrative health modality, mode intervention delivery, study quality and limitations, and intervention intensity.

Results

Study Identification

The search yielded 169 unique articles (Figure 1). After 109 exclusions in the title and abstract review phase, full-text review was conducted on 60 articles. After excluding 47 articles (most commonly because the study was not an intervention [n=11 articles] or did not match age criteria [n=10]), 12 articles covering 10 intervention studies were reviewed and synthesized (Table 1). One intervention – SENSE – was included in three studies: one assessing primary post-intervention effects (M. Blake et al. 2016), one mediating effects (M. Blake et al. 2017), and one moderating effects and subgroup effects (M. J. Blake et al. 2018).

Table 1.

Characteristics of Participants and Study Setting

Author, Year	Participants				Setting
	Total N	Age Range (Mean) in Years	Female (%)	Health Conditions (inclusion/exclusion)	Country	Recruitment
Antonson et al., 2018	283 (iMBI=95; iMT-94; WL=94)	15 – 19 (16.9)	74	n/a	Sweden	Secondary schools
Bartel et al, 2018	232 (CW=107; mindfulness=70; control=55)	14 – 18 (15.9)	81	Did not exclude if had sleep problems or anxiety treatments	Australia	Secondary schools
Bei et al, 2013	10	13 – 15	100	Poor sleep quality as measured by the PSQI	Australia	Private school for girls
Blake et al, 2016 a	144 (71 intervention; 73 control)	12 – 17 (14.5)	60	Poor sleep quality and high levels of anxiety Excluded those with major depressive disorder, history of bipolar or psychotic disorder, history of head injury, currently using anxiolytics or hypnotic medication	Australia	Secondary schools
Blake et al, 2017 a	123 (63 intervention; 60 control)
Blake et al, 2018 a	123 (63 intervention; 60 control)
Hirokawa et al, 2012	18 (9 intervention, 9 control)	Range NR (19.0)	67	Excluded those with a diagnosis of sleep insomnia or who used sleep aids	Japan	College psychology department
Jeitler et al, 2017	92 (54 intervention, 38 control)	17 – 29 (19.6)	53		Germany	Vocational secondary schools
Manzaneque et al, 2009	39 (21 intervention, 18 control)	18 – 21 (NR)	87	Excluded those taking any type of drugs or if have a "pathological condition"	Spain	Psychology students at University of Malaga
Swanson et al, 2016	22 consented; 12 with pre- and post-data	18 – 24 (NR)	NR		USA	Long term housing units for homeless youth
Vera et al, 2019	43 (22 intervention, 21 control)	18 – 22 (19.8)	77		Spain	Psychology students at University of Malaga
Zelic et al, 2018	65 (32 intervention, 33 control)	14 – 18 (NR) 54% ranged in age from 17 – 18	62		USA	High schools

^a= Sample sizes are smaller in Blake 2017 and Blake 2018 because they presented, respectively, mediation analyses and effect modification analyses, and participants had missing data precluding their inclusion in the analyses.

Abbreviations: CW = Constructive Worry; iMBI = internet-based Mindfulness-based Intervention; iMT = internet-based Music Therapy; NR = Not reported; PSQI = Pittsburgh Sleep Quality Inventory; WL = Wait list

Study Designs

The majority of studies used a two-arm (M. Blake et al. 2016; M. Blake et al. 2017; M. J. Blake et al. 2018; K. Hirokawa et al. 2012; Jeitler et al. 2020; Manzaneque et al. 2009; Zelic 2017) or three-arm (Antonson et al. 2018; Bartel et al. 2018) individual-level randomized controlled trial design with single blinding (Table 2). Two of the RCTs used an active control arm, with control conditions of music therapy (Antonson et al. 2018) and study skills (M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018). Only three studies did not use a randomized design: one study of yoga had a non-randomized comparison group engaged in physical education class (Jeitler et al. 2020), while two studies used a single-group pre/post design (B. Bei et al. 2013; Swanson and Harpin 2016). Sample sizes ranged from 10 participants (B. Bei et al. 2013) to as large as 283 participants in an internet-based intervention (Antonson et al. 2018) (Table 1).

Table 2.

Study Characteristics

	Study Design		Intervention description		Outcomes
Author, Year	Type	Follow-Up Period (post-intervention	Active Intervention	Comparator	Sleep	Other
Antonson et al., 2018	RCT, three arms	Immediate post-intervention	Internet-based mindfulness Format: internet-based Delivered by: Self-directed viewing of videos developed by a “renowned national expert” on clinical mindfulness meditation Duration: 8 weeks Frequency: Twice daily, 6 days a week (96 total sessions) Session length: 10 minutes Content: Standard mindfulness meditation techniques (e.g., body scan and mindfulness of breadth and other perceptions), elements of MBSR and cognitively-oriented elements from MBCT	Comparator 1 (active): Internet-based Music Therapy Format: internet-based Delivered by: Self-directed, videos on YouTube Duration: 8 weeks Frequency: Session length: 10 minutes Content: non-vocal classical music pieces recognized as calming or soothing Comparator 2: Wait-list Control	Subjective: Sleep quality global score (PSQI)	Perceived stress (Perceived Stress Scale, PSS-14); General psychiatric symptoms (SCL-90)
Bartel et al., 2018	RCT, three arms	Immediate post-intervention; assessment at midpoint of intervention	Mindfulness Format: MP3 audiofile Delivered by: Self-directed, Intervention instructions given verbally and in writing on baseline questionnaires Duration: 2 weeks Frequency: nightly, at bedtime Session length: 15 minutes Content: Breath-based body scan: breathing, sequential awareness of each section of the body.	Comparator 1 (active): Constructive worry Format: written Delivered by: Self-directed Frequency: nightly, at bedtime Content: write down at night at least 3 worries that may keep them awake, next step to resolve, if worry surfaced remind self they had solved the problem best they could. Comparator 2: Sleep/wake habits as usual	Subjective: SOL (school week, weekend); sleep hygiene (ASHS cognitive emotional subscale)	Negative thinking or rumination (PTQ-C); Daytime sleepiness (SRSQ)
Bei et al., 2013	Single group, pre/post design	Immediate post-intervention	Mindfulness Format: Group Delivered by: Clinical psychologist, educational psychologist Duration: 8 weeks (2 week break) Number of sessions: 6 Frequency: Weekly Session length: 90 minutes Content: MBCT and cognitive-behavioral principles. Sleep quizzes at each session. Breath awareness mindfulness, guided mindfulness. Personalized goals for sleep scheduling.	None	Objective: Actigraphy over 7 days: TST, bed time, rise time, SOL, SE, WASO Subjective: Sleep quality global score and subjective sleep quality (PSQI), sleep disturbance, TST, SOL, SE	Anxiety symptoms and subscales (SCAS); psychopathology and mood disorders (K-SADS)
Blake et al., 2016 Blake et al., 2017 Blake et al., 2018	RCT, two arms; randomization stratified by gender, age, presence of current anxiety disorder	Immediate post-intervention; 18 months; 24 months (18 and 24 month follow-up not yet published)	Sleep SENSE Format: Group, 6–9 participants Delivered by: Teacher Duration: 7 weeks Number of sessions: 7 Frequency: Weekly Session length: 90 minutes Content: Cognitive-behavioral and mindfulness-based, sleep education, sleep hygiene, stimulus control, and cognitive restructuring; mindfulness- and anxiety-specific components; workbook; tracking behavior change; parental information. Encouraged to practice at home.	Study SENSE Format: Group, 4–9 participants Delivered by: Teacher Duration: 7 weeks Number of sessions: 7 Frequency: Weekly Content: Study skills; organization; active listening; note taking; memory; test-taking; presentation.	Objective: Actiwatch, with paper sleep diary, for 7 days: TST; SOL; SE; WASO; bedtime (BT). Subjective: Sleep quality (PSQI), with poor sleep quality cutoff of 5 or above; daytime sleepiness (PDSS): TST; SOL; SE	Anxiety (SCAS); Depression (CES-D), Self-Efficacy (General Self-Efficacy Scale); Affective and psychotic disorders (K-SADS) Sleep knowledge
Hirokawa et al., 2012	RCT, two arms	Immediately post-intervention (3 days post)	Lavender aromatherapy Format: Individual, at home Delivered by: Self-directed following instructions by the study team, and guidance on expected effects. Duration: 5 days Frequency: Each night, at bedtime Content: Received a bottle of aroma that contained a rolled 5 x5 cm gauze patch soaked in commercially produced lavender aromatherapy oil. Instructed to place by their bed and open them before going to sleep. Information on calming effect of aroma (expectancy).	Format: Individual, at home Delivered by: Self-directed Duration: 5 days Frequency: Each night, at bedtime Content: No lavender; provided with a bottle with a gauze patch soaked in water	Subjective: Sleep quality (Oguri-Shirakawa-Azumi Sleep Inventory for middle-aged and older adults [1999]); sleep duration (sleep diary).	No other outcomes assessed.
Jeitler et al. 2017	Non-randomized, controlled, two arms	Immediately post-intervention; 6-months follow-up (mail). Two baseline assessments (once before a holiday, after 3 week holiday)	Yoga Format: Group Delivered by: Certified yoga teachers with 20+ years’ experience Duration: 10 weeks Number of sessions: 10 Frequency: Weekly Session length: 90 minutes Content: Perception exercises; warm-up; more intensive yoga practice; transition to relaxation; breathing. Encouraged to practice at home.	Active school sports Format: Group Delivered by: Instructor Duration: 10 weeks Number of sessions: 10 Frequency: Weekly Session length: 90 minutes Content: Group sports (basketball, volleyball, floor hockey, and badminton) with warm-up and cool-down.	Sleep was not primary outcome Subjective: Assessed over 7-day reference period using 100 mm visual analogue scales (VAS), for “exhaustion” and “sleep.”	Primary outcome: Perceived stress (Perceived Stress Scale in German); Anxiety and depression (HADS); Quality of life and wellbeing (WHO-Five Well-being index); current mood (German version of the Profile of Mood States).
Manzaneque et al., 2009	RCT, two arm, randomization stratified by sex	Immediate post-intervention	Qigong Format: Group and individual Delivered by: Qualified instructor Duration: One month Number of sessions: 20 sessions Frequency: 3 group sessions per week, individual sessions (1 during the week, 1 weekend) Session length: 30 minutes (group), 15 minutes (individual) Content: Ba Duan Jin qigong (8 sets of 8 distinct movements). Encouraged to practice at home.	Follow daily life habits	Subjective: Sleep quality (PSQI).	Anxiety (STAI, BAI); Depression (BDI). Serum cytokines (TNF-α, IFN-γ
Swanson et al., 2016	Single group, pre/post design	Immediate post-intervention	Mindfulness Format: Group Delivered by: Certified mindfulness instructor Duration: 4 weeks Number of sessions: 4 Frequency: Weekly Session length: 60 minutes Content: Mindfulness, adapted for needs of homeless youth	None (single arm study)	Subjective: Sleep quality (PSQI)	Depression (CES-D); dispositional Mindfulness (Mindful Attention-Awareness Scale-Adolescent);Self-compassion (Self-Compassion Scale-Short Form)
Vera et al., 2019	RCT, two arms	Immediate post-intervention	Taoist qigong Format: Group and individual Delivered by: Qualified qigong instructor Duration: One month Number of sessions: 15–20 sessions (10–12 group, 5–8 individual) Frequency: 3 group sessions per week, individual sessions (varied but 1 during the week, 1 weekend) Session length: 25–30 minutes (group), 12–15 minutes (individual) Content: Taoist qigong (7 discrete movements, repeated 6 times). Encouraged to practice on own.	Regular daily habits and routines	Subjective: Sleep quality (PSQI); SOL; SE; sleep duration; sleep disturbances	Anxiety (STAI); Depression (BDI). Stress hormones (ACTH, cortisol, and DHEA-S)
Zelic et al., 2018	RCT, two arms	Immediate post-intervention; 2 weeks post-intervention	Mindful relaxation Format: MP3 audiofile Delivered by: Self-directed Duration: 6 nights Frequency: Each night before sleeping Session length: 4 minutes Content: Recording of mindfulness-based relaxation exercise based on MBSR. Breathing awareness, let thoughts and feelings come and go.	No change to sleep routine	Objective: Actigraphy using Actiwatch-II for 7 days: SE, sleep duration, TST, SOL, number of awakenings Subjective: Sleep quality (PSQI); sleep habits Sleep-Wake Scale (ASWS). Subjective feeling rested, sleep quality. Sleep diary based on PSQI.	Depression (CES-D); Anxiety (SCARED; Affect (PANAS-X); rumination (shortened daily version Response Style Questionnaire, rumination Scale; and shortened daily version Penn State Worry Questionnaire); mindfulness (shortened daily version Five-Facet Mindfulness Questionnaire); Measure of Perceived Overscheduling

Abbreviations: ACTH = adrenocorticotropic hormone; ASHS = Adolescent Sleep Hygiene Scale; ASWS = Adolescent Sleep Wake Scale; BAI = Beck Anxiety Inventory; BDI = Beck Depression Inventory; CESD = Center for Epidemiological Studies – Depression; DHEA-S = Dehydroepiandrosterone sulfate; HADS = Hospital Anxiety and Depression Scale; K-SADS = Schedule for Affective Disorders and Schizophrenia for School-Aged Children; MBCT = mindfulness-based cognitive therapy; MBSR = mindfulness based stress reduction; PANAS-X = Positive and Negative Affect Scale - Expanded Form; PDSS = Pediatric Daytime Sleepiness Scale; PSQI = Pittsburgh Sleep Quality Index; PTQ-C = Perseverative thinking questionnaire, children; RCT = randomized, controlled trial; SCAS = Spence Children’s Anxiety Scale; SCARED = Screen for Child Anxiety Related Disorders; SCL-90 = Symptom checklist-90; SE = sleep efficiency; SOL = sleep onset latency; SRSQ = sleep reduction screening questionnaire; STAI = State-Trait Anxiety Inventory; TST = total sleep time; WASO = wake after sleep onset

Intervention Characteristics

The most common mind-body integrative health modality tested was mindfulness (Table 2); six interventions used elements from mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT) (Antonson et al. 2018; Bartel et al. 2018; B. Bei et al. 2013; M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018; Swanson and Harpin 2016; Zelic 2017). Mindfulness activities included body scans, mindfulness of breath, skills for managing worries at bedtime and paying attention and awareness to the present moment. The interventions that did not focus on mindfulness used qigong (the practice of certain postures and gentle movements with mental focus, breathing, and relaxation) (Manzaneque et al. 2009; Vera et al. 2019), aromatherapy (K. Hirokawa et al. 2012), and yoga (Jeitler et al. 2020).

Just over half of the studies (M. J. Blake et al. 2018; M. Blake et al. 2016; M. Blake et al. 2017; K. Hirokawa et al. 2012; Jeitler et al. 2020; Zelic 2017) delivered the intervention in a group format, with the two types of qigong interventions being delivered in a combination of group and individual sessions (Manzaneque et al. 2009; Vera et al. 2019); experts or professionals led group sessions lasting 30 to 90 minutes. Four interventions were self-directed, providing participants with instructions or materials to engage with at home: one was internet-based, with 10-minute mindfulness sessions to be completed twice a day (Antonson et al. 2018); one provided intervention participants with bottles containing lavender oil, instructing them to leave them open by their beds (K. Hirokawa et al. 2012); and two provided participants with a mindfulness audio recording, with instructions to listen to the recording before bed (Zelic 2017; Bartel et al. 2018).

Intervention durations ranged from as short as five days (K. Hirokawa et al. 2012) and seven days (Zelic 2017) to as long as 10 weeks (Jeitler et al. 2020). The self-directed interventions (Bartel et al. 2018) were conducted nightly or more frequently (Antonson et al. 2018), those that combined group and individual sessions met several times per week (Manzaneque et al. 2009; Vera et al. 2019), with the remainder meeting weekly (B. Bei et al. 2013; M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018; Jeitler et al. 2020; Swanson and Harpin 2016). The most participation-intensive intervention, offered 96 brief internet-based sessions over eight weeks (Antonson et al. 2018).

Participants

Almost all of the interventions (9 of 10), which took place across the globe (Australia, Germany, Japan, Spain, Sweden, and the United States [US]), enrolled student participants in secondary school or university settings. Only one intervention, US-based, took place in a long-term housing unit with participants who were homeless (Swanson and Harpin 2016). Participants were predominantly (53 – 100%) female, ranging in age from 12 to 29 years. Only one study (Zelic 2017) reported participants’ race and ethnicity data: the US-based participants were 81% non-Hispanic white, 9% Black or African American, 3% Hispanic or Latinx, 3% Asian, 2% American Indian/Alaska Native, and 2% Hawaiian/Other Pacific Islander.

As this review was focused on interventions intended for the general population of adolescents and young adults, the studies included participants without a diagnosis of a chronic condition; however, participants could report symptoms related to health issues. One intervention was restricted to participants with symptoms of anxiety and poor sleep (the SENSE intervention by Blake et al.) (M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018), and two other interventions included substantial proportions of participants with poor sleep, anxiety symptoms, and/or depressive symptoms (Bartel et al. 2018; Manzaneque et al. 2009).

Outcomes Assessed

Sleep outcomes.

All studies assessed sleep outcomes through self-report (Table 2). The most commonly assessed subjective outcome was sleep quality as measured by the global score on the Pittsburgh Sleep Quality Index (PSQI). Other subjective sleep quality dimensions (e.g., sleep duration and sleep onset latency) were assessed using component scores of the PSQI and/or through sleep diaries. Two of the studies used other instruments to assess daytime functioning and sleepiness, using a visual analog scale (Jeitler et al. 2020) and the Sleep Reduction Screening Questionnaire (Bartel et al. 2018). Only three of the 10 studies measured sleep objectively using actigraphy (M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018; B. Bei et al. 2013; Zelic 2017), including sleep onset latency, time to bed and to wake, total sleep time, and sleep efficiency.

Other outcomes.

With only one exception (K. Hirokawa et al. 2012), all of the studies assessed additional outcomes (Table 2), primarily measuring psychological well-being, including anxiety symptoms (B. Bei et al. 2013; M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018; Manzaneque et al. 2009; Vera et al. 2019), depressive symptoms (Zelic 2017; M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018; Manzaneque et al. 2009; Vera et al. 2019), negative thinking and rumination (Zelic 2017; Bartel et al. 2018), affective disorders (M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018), perceived stress (Antonson et al. 2018; Jeitler et al. 2020), and general psychiatric health (Antonson et al. 2018; Jeitler et al. 2020; M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018). The two qigong studies (by the same study team) also assessed biomarkers: the study of baduanjin qigong (Manzaneque et al. 2009) measured serum cytokines (TNF-alpha and IFN-gamma) that are hypothesized to play a role in immune function (Ovington et al. 1995), while the study of Taoist qigong assessed three Hypothalamic-Pituitary-Adrenal (HPA) axis hormones hypothesized to be related to stress, anxiety, depression, negative mood, and poor sleep quality (Capaldi Ii et al. 2005). Only one study explicitly examined mediating effects, with the SENSE study identifying improvements in the somatic and cognitive pre-sleep arousal subscales(M. Blake et al. 2017).

Intervention Participation & Adherence

All studies reported program participation, completion or adherence (Table 3), with wide-ranging findings: while Antonson et al. reported only 16% of participants initiating the intervention (Antonson et al. 2018), others had high rates, with SENSE participants completing 76% of the sessions (M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018); Zelic et al., reporting that 82% listened to all intervention audio content from their MP3 based intervention (Zelic 2017); and Bei et al. reporting 90% program completion (5 of 6 planned sessions) (B. Bei et al. 2013). SENSE participants reported practicing mindfulness once or twice a week for five minutes at a time. In the Antonson et al. study (Antonson et al. 2018), only 15 participants out of the 95 randomized to the mindfulness arm started the intervention, and only one participant completed 40 of the 96 online sessions, considered full participation.

Table 3.

Intervention Participation, Adherence, Effects & Limitations in Study Quality

				Limitations in Study Quality
Author et al., Year	Participation & Adherence	Impact on Sleep Outcomes (Subjective, Objective, Participant Ratings)	Impact on Other Outcomes	Study Design	Outcome Assessment & Follow-Up	Quality of Intervention Implementation	Participants & External Validity
Antonson et al., 2018	Intervention Participation: Of the 95 randomized to iMBI, only 14 completed ≥ 1 session, of whom 4 completed ≥10 sessions. Only 1 person completed the iMBI intervention, defined as completing ≥40 of 96 planned sessions. Research Protocol: Only 3 of the 4 the participants who completed ≥10 iMBI sessions completed post-intervention assessments. No association between compliance and stress or psychiatric symptoms.	Insufficient statistical power to examine sleep outcomes. The only participant who completed iMBI sessions decreased PSQI global score 8 to 7.	Only participant who completed iMBI sessions decreased GSI by 31% (from 0.80 to 0.55), PSS from 29 to 23.		Insufficient statistical power given low adherence. No follow-up assessment of outcomes.	Low intervention participation and adherence.	Low uptake of the intervention at the recruitment school. Consented only 283 out of 1403 (20%) and only 202 completed baseline surveys (71% of those consented or 14% of the school sample).
Bartel et al., 2018	Intervention Participation: Self-reported. Classified as completer if 3 or more nights intervention for 1 or more weeks 71% (50/70) completed Mindfulness.	No significant time arm*time interaction for SOL, overall (p=0.17) or for the subset (n=119) who had SOL of 30 minutes or more at baseline (p=0.07). Mindfulness arm reduced SOL only among those with long SOLs, if performed for at least 3 nights/week. For the group of completers with baseline SOL ≥ 30 minutes, significant arm*time interaction (p=0.001): 65.35 to 34.60 minutes. No significant findings for sleep hygiene (ASHS). Perceived Effectiveness: Perceived efficacy of intervention among mindfulness participants: problems falling asleep improved a lot (31.6%) or a bit (45.5%). Intervention was highly (6.1%) or somewhat effective (38.8%).	No significant impacts on rumination (PTQ-C).		Did not objectively measure sleep. Social desirability in reporting possible. Assessment at mid-intervention but no follow-up assessment of outcomes.	Adherence (subjectively measured) was low. Mindfulness audio needed “improving” according to adolescent participant qualitative feedback.	Listening to audio not mindfulness per se may be operating.
Bei et al., 2013	Intervention Participation: 90% completion rate (completed 5 of 6 planned sessions). Research Protocol: One actigraph did not work; 8 participants had actigraphy data.	Objective: Moderate improvements for SOL (Cohen’s d = 0.53; 17 min decrease) and SE (Cohen’s d = −0.51). Participants who took ≥30 minutes to fall asleep fell from 70% to 35.75% post-intervention. Small improvement for total sleep time (Cohen’s d = −0.46, 20 more minutes of sleep/night). Changes in regularity of bed time and rise time were small (Cohen’s d = 0.27 & −0.21, respectively). Post-intervention, participants went to bed on average 35 minutes earlier and woke up 40 minutes earlier. No significant impact on WASO. Subjective: PSQI global scores improved moderately (Cohen’s d = 0.51). Large improvement in subjective sleep quality (Cohen’s d = 0.84). SOL had large improvement (Cohen’s d = 0.80; 19 minute reduction). Participants who took ≥30 minutes to fall asleep reported taking 30 min or longer to fall asleep decreased from 90% to 55.56%. No significant difference in self-reported: TST, SE, subjective sleep disturbance, or sleep-related daytime dysfunction. Perceived Effectiveness: Out of 7, the average rating of overall perceived helpfulness was 5.44 (SD = 0.73).	No statistically significant differences in anxiety or mood disorders.	Single-arm design without control group.	Adherence was not measured. No follow-up assessment of outcomes. Pre- and post-intervention assessments were both measured during holidays.		Small sample size. Only females. Not clear what most effective component of intervention was (it was multi-component).
Blake et al., 2016	Intervention Participation: Participants attended approximately 76% of sessions on average. In total 5 participants (4 intervention, 1 control) did not complete at least 4 of the 7 intervention sessions. Research Protocol: 20 participants (10 intervention, 10 control) were randomized but did not initiate intervention. Low missing data for questionnaire (6.2%) and actigraphy (6.1%), slightly higher for sleep diary variables (14.6%). Participants wore the actiwatch on 4.5 of the 5 nights. Participants completed sleep diaries on 3.75 of the 5 school nights. Of participants, 4 declined to provide post-intervention data.	Objective: Significantly improvements compared to control in objective SOL. No improvements in WASO. Subjective: Significant improvements in subjective SOL, subjective sleep quality (PSQI global score), subjective daytime sleepiness. No significantly greater improvements in objective or subjective total sleep time. Perceived Effectiveness: Believed got something of value: Sleep SENSE 100% vs. Study SENSE (active control) 96%. Sleep SENSE participants rated the program as more useful than controls (p<.01). Sleep participants reported practicing mindfulness (5 or more minutes a time) 1 – 2 times/week. Most helpful sleep components: mindfulness of the breath, going to bed.	After controlling for baseline values, compared to controls, immediate post-intervention, sleep participants had less anxiety, but not less depression.				A multi-component intervention: canť tease out which components worked. Those with most severe symptoms were more likely to enroll and be engaged once enrolled. Excluded those with major depressive disorder.
Blake et al., 2017	As above (Blake 2016).	Objective: Assessed direct effects using modified intent to treat (including non-completers but not non-initiators). Intervention participants had shorter sleep onset latency measured with actigraphy (p=0.004). Subjective: Better sleep efficiency measured with diary (b=9.97, p=0.044), and better global sleep quality (PSQI b=1.07, p=0.001) compared to control participants. Mediation: Assessed mediation - found significant indirect effects for sleep quality (PSQI) and anxiety (SCAS) through improvements in presleep arousal (PSAS), somatic and cognitive subscales.	Intervention resulted in: less anxiety symptoms, less pre-sleep somatic arousal, less presleep cognitive arousal and better sleep hygiene awareness.				No dose-response effect observed. Did not detect specific effects based on intervention components.
Blake et al., 2018	As above (Blake 2016).	Moderation: Assessed gender and baseline sleep duration, anxiety, depression, and self-efficacy as moderators. For PSQI, anxiety, depression, and self-efficacy were moderators (stronger intervention effects among those with higher anxiety and higher depression and higher self efficacy scores at baseline), but not gender. No significant moderation on sleep onset latency (SOL) or sleep efficiency (SE) for any moderators tested.	Low levels of self-efficacy may need additional targeted support				Common variance across the moderator variables. Other possible moderators (such as age) not assessed. Excluded those with major depressive disorder.
Hirokawa et al., 2012	3 participants (2 intervention, 1 control) dropped from intervention.	“Improved sleepiness at awakening” (mean score 12.2 pre, 16.3 during, 17.7 post for intervention; 13.7, 11.2, 12.1 respectively for control; p<0.01); “experiencing persistence of fatigue” (11.9, 16.9, 20.4 for intervention; 18.2, 12.4, 14.6 for control, p<0.001); “being able to formulate an answer” (12.5, 17.1, 15.1 for intervention, 10.3, 8.7, 9.4 for control, p<0.01). No significant group X time effects for alleviation of tiredness, longer duration of sleep, or sleep hours.	No significant effect of sex for quality of sleep on any subscores. No difference in effects across the 5 days of the intervention.	Used water as a comparator, rather than an aroma other than lavender.	No objective measurement of sleep outcomes. Social desirability response bias is possible. No follow-up assessment of outcomes. Sleep diary not analyzed due to privacy concerns. Did not assess known factors related to sleep quality (caffeine, being active before). Did not assess any outcomes other than sleep.	Intervention was delivered by study team interventioninst, but the mind-body training for the interventionist was not described. Adherence to intervention was not assessed.
Jeitler et al., 2017	Research Protocol: 5 participants (4 intervention, 1 control) lost to follow-up by immediate end of intervention; 33 (22 intervention, 11 control) lost to follow-up at 6 month intervention.	No significant improvements from baseline in sleep (as measured with visual acuity scale) immediately post-intervention or at 6-month follow up	No significant differences in PSS between groups immediately post-intervention or at 6-month follow up. Twice as many side effects reported in the yoga intervention group compared to control, with 4 reporting headache after yoga class.	Groups were not comparable due to lack of randomization. Intervention group had higher baseline scores of perceived stress, depression and anxiety. Intervention participants attended school sports (control condition) after the 10 week intervention period.			Substantial loss to follow up at 6 months.
Manzaneque et al., 2009	Intervention Participation: 6 participants (5 intervention, 1 control) did not complete intervention.	Subjective: No significant difference in post-intervention PSQI global score (4.84 intervention vs. 5.27 control, p=0.83), but statistically significant difference in sleep duration.	No significant differences in post-intervention serum cytokines (TNF-alpha or IFN-gamma). Significantly (p<0.01) better outcomes for intervention for anxiety (STAI) and depression (BDI).	Comparator was not active control (“follow daily life habits”). Small sample size.	No objective measurement of sleep outcomes. No follow-up assessment of outcomes.		Participants were general healthy population, not those with sleep problems at baseline.
Swanson et al., 2016	Intervention Protocol: Low adherence (3 youth completed one or two sessions and 8 youth completed three to four sessions) Research Protocol: In total, 12 of 22 had complete pre/post data; 8 youth had no post-surveys or session attendance data.	Subjective: Among those with complete data (n=12), overall sleep quality improved significantly (PSQI-Q6 change = 0.67;p< .05).	Non-significant improvement in mental distress (CES-D change = 4.16,p= 0.036) or self-compassion SCS-SF change = 0.11,p= 0.64). No significant change in mindful state (MAASA p=0.86).	Small sample size. Single-group design without comparator.	No objective measurement of sleep outcomes. No follow-up assessment of outcomes.	Low adherence to intervention and high attrition due to unstable housing.
Vera et al., 2019	Research Protocol: 5 lost to follow-up. No statistically significant differences in baseline char between those with and without complete data.	Subjective: No significant difference in subjective sleep quality (3.63 in Control vs. 3.48 in intervention - p=0.77). Notably, scores are lower (indicating better sleep) compared to baseline PSQI (4.65, 5.14 respectively).	In the intervention group, compared to controls: significantly lower ACTH (19.65 vs. 24.06, p=0.02), but no significant differences in Cortisol, DHEA-S, or measures of anxiety (STAI) or depression (BDI)	Small sample size. Comparator was not active control (“regular daily life habits”)	No objective measurement of sleep outcomes. No follow-up assessment of outcomes.	Short duration of intervention.
Zelic et al., 2018	Intervention Protocol: Experimental group had 82% compliance in listening to intervention. Research Protocol: 65 of 86 participants provided ≥3 days of data (in 7 days intervention) and were retained in analyses. Three participants withdrew from study	No significant between-group differences between the mindfulness and control conditions on any measure including objective or subjective sleep indices. Assessed depression, rumination, anxiety, worry, and gender as moderator of sleep outcomes. Participants with poor baseline overall sleep quality in the mindfulness condition had longer sleep duration (p <.05). High ruminators in the mindfulness condition obtained significantly more sleep time (p < .05). Females in the mindfulness condition obtained a significantly greater amount of sleep compared to females in the control condition (p < .05), but no significant effect in males.	No significant between-group differences between on non-sleep outcomes.	Comparator was not active control (“no change to sleep routine”)		Low adherence led to insufficient sample size. Short study duration/low intensity.	Homogeneous sample. Barriers to recruitment due to skepticism about possible Buddhism connotation of mindfulness.

Abbreviations: ASHS = Adolescent Sleep Hygiene Scale; BDI = Beck Depression Inventory; CES-D = Center for Epidemiological Studies – Depression; GSI = general psychiatric symptoms subscale of Symptoms Checklist-90; iMBI = Internet-based mindfulness-based intervention; MAASA = Mindful Attention Awareness Scale; PSAS = Pre-sleep Arousal Scale; PSQI = Pittsburgh Sleep Quality Index; PSS = Perceived Stress Scale; PTQ-C = Perseverative Thinking Questionnaire, children; SCAS = Spence Children’s Anxiety Scale; SCS-SF = Self-Compassion Scale, Short Form; SE = sleep efficiency; SOL = Sleep onset latency; STAI = State-Trait Anxiety Inventory; TST = total sleep time; WASO = wake after sleep onset

Intervention Effects

Sleep outcomes.

Efficacy and effectiveness of the interventions in improving sleep were mixed (Table 3). Half of the studies reported significant improvements in subjective sleep quality, assessed using the PSQI (B. Bei et al. 2013; Antonson et al. 2018; M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018; Swanson and Harpin 2016). Improvements were also seen in other subjective assessments including sleep duration (Manzaneque et al. 2009), sleep efficiency (M. Blake et al. 2017), and daytime sleepiness (M. Blake et al. 2016; K. Hirokawa et al. 2012). No study found significant effects across all dimensions of sleep assessed. Only three studies (Zelic 2017; Jeitler et al. 2020; Vera et al. 2019) found no significant improvements in subjective sleep in their study samples as a whole. Two of the three studies measuring sleep objectively found improvements across the sample: Bei et al. reported moderate impacts in both sleep onset latency (Cohen’s d=0.53) and sleep efficiency (d=0.51), with slightly lower effect for total sleep time (d=0.46) (B. Bei et al. 2013); using actigraphy data, the proportion of participants who took 30 minutes or longer to fall asleep decreased from 70% at baseline to 36% post-intervention. Of note, Bei et al. found larger effect sizes for sleep onset latency when it was self-reported (d=0.80). Similarly, the SENSE study found improvements in objective sleep onset latency, with medium effect sizes (M. Blake et al. 2016).

Few of the studies assessed outcomes beyond post-intervention, with varying durations of follow-up (2 weeks by Zelic et al. (Zelic 2017), 6 months by Jeitler et al. (Jeitler et al. 2020)), and neither of these studies observed sustained positive effects. The Sleep SENSE intervention by Blake et al. (M. J. Blake et al. 2018) will assess outcomes at 18- and 24-months post-intervention (not published at the time of manuscript development).

Other outcomes.

Of the six studies that assessed psychological well-being, only three reported improvements in psychological well-being, including improvements in anxiety symptoms (M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018; Manzaneque et al. 2009), depressive symptoms (Manzaneque et al. 2009), and perceived stress (Antonson et al. 2018) (Table 3). Only one study (M. Blake et al. 2017), which included only participants with poor sleep quality and anxiety symptoms at baseline, explicitly examined mediating mechanisms, and found that measured improvements in the Pre-Sleep Hyperarousal Scale (PSAS) specifically mediated the observed improvements in anxiety and subjective sleep quality (but not sleep onset latency). Of the two qigong studies that assessed biomarkers, one found significant differences in adrenocorticotropic hormone (ACTH) but not the other two HPA-axis hormones studied (Vera et al. 2019), while the other found no significant effects on cytokines (Manzaneque et al. 2009).

Moderating factors and subgroup analyses.

Several of the studies that did not observe significant improvements in the overall study sample, did find improvements when conducting subgroup analyses. The Australian secondary school-based mindfulness study (Bartel et al. 2018), for instance, found significant reductions in sleep onset latency among the subset of participants who completed the intervention (i.e., used the mindfulness audio recording at least 3 nights in at least 1 of the 2 weeks) and reported ≥30 minutes sleep onset latency at baseline. The SENSE study found differential effects on subjective sleep quality as measured by the PSQI among those with higher baseline levels of anxiety, depression, and self-efficacy (M. J. Blake et al. 2018); the moderation effect was observed for the findings on actigraphy-measured sleep onset latency and sleep efficiency measured using sleep diaries. The Zelic study (Zelic 2017), which used audio recorded mindfulness content, found no significant effects across the sample in general, but found statistically significant increases in sleep duration and sleep time among those with higher depressive symptoms and higher ruminative scores at baseline; improvement in sleep duration was found only for individuals with worse baseline self-rated sleep quality. In terms of sociodemographic subgroup analyses, the SENSE study explored gender as a potential moderator of treatment efficacy but did not find significant differences. No study explored age as a moderating factor.

Participant ratings.

Three of the ten studies (M. Blake et al. 2016; B. Bei et al. 2013; Bartel et al. 2018) collected data from participants on their satisfaction and perceived usefulness or effectiveness of intervention content. Generally, participant ratings were higher in the studies that observed improvements in sleep in the whole sample when compared to studies that did not.

The study of mindfulness among adolescent girls by Bei et al. reported that the average rating of overall perceived helpfulness was 5.44 (SD = 0.73) on a scale from 1 (not helpful at all) to 7 (very helpful). In the SENSE study, all of the sleep intervention participants reported getting something of value, and they were significantly more likely than controls to rate the program as useful (M. Blake et al. 2016). Specifically, they found mindfulness of the breath and going to bed activities as the most useful.

The mindfulness-based intervention in Australian secondary school by Bartel et al., whose intervention resulted in significant sleep onset latency improvements only among those who had poor sleep onset latency at baseline and completed the intervention, found that only half of mindfulness intervention participants felt their sleep improved (6% a lot, 46% a little), and just over half perceived the intervention as being effective (6% highly, 50% somewhat) (Bartel et al. 2018).

Limitations in Study Quality.

This synthesis identified several limitations in the quality of the studies examined (Table 3). Two of the studies used a single group design and thus could not rule out temporal effects (Bei Bei et al. 2013; Swanson and Harpin 2016), three others (Kumi Hirokawa et al. 2012; Manzaneque et al. 2009; Zelic 2017) used a two-group design without an active comparator and thus could not rule out expectancy or placebo effect; and one study (Jeitler et al. 2020) had a two-group design without randomization, so that lack of comparability between the two groups could not be ruled out. In terms of outcome assessment, four studies (Antonson et al. 2018; Bartel et al. 2018; Kumi Hirokawa et al. 2012; Manzaneque et al. 2009) used only subjective assessment of sleep outcomes, and thus could not rule out social desirability response bias. Only two studies (Jeitler et al. 2020) assessed outcomes beyond the immediate post-intervention, and thus it is difficult to draw conclusions on the lasting impact of interventions. Finally, four of the studies experienced attrition from intervention activities and/or research procedures that exceeded 15% of the sample (Antonson et al. 2018; Kumi Hirokawa et al. 2012; Swanson and Harpin 2016; Vera et al. 2019), resulting in small sample sizes, the potential for over- or under-estimation of intervention effects due to attrition bias, and limiting external validity.

Discussion

This study was undertaken to 1) describe and synthesize the evidence base on mind-body integrative health interventions to improve sleep among adolescents, an area of inquiry that has not previously been undertaken, and 2) to identify gaps in the published evidence to guide potential avenues for future intervention work. This scoping review identified a broad diversity in mind-body integrative health sleep interventions for adolescents in terms of the format and content of the interventions and their impact on sleep outcomes. There were mixed findings on the promise of mind-body integrative health approaches to improve sleep among adolescents, with many studies observing statistically significant effects only among subgroups of participants with poor sleep quality (notably, high sleep onset latency) or higher levels of anxiety at baseline.

Mindfulness interventions showed promise, while two studies of two types of qigong had mixed results: one using Ba Duan Jin qigong found improvements in sleep duration, anxiety symptoms and depressive symptoms, but no improvement in the stress hormones studied (Manzaneque et al. 2009); the other using Taoist qigong did not improve sleep, anxiety symptoms or depressive symptoms, but did find improvements in ACTH, one of the three stress hormones studied (Vera et al. 2019). The studies of yoga (Jeitler et al. 2020) and aromatherapy (K. Hirokawa et al. 2012) (only one intervention each) did not yield significant improvements when the participants were considered as a whole.

Two of the interventions stand out in that they assessed sleep objectively, and observed statistically significant improvements in sleep onset latency in the entire study population: the SENSE study (M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018) and the intervention that combined mindfulness with stress- and anxiety-specific content (B. Bei et al. 2013). These two interventions both used a combination of mindfulness-based stress reduction and mindfulness-based cognitive therapy, and the content was delivered in weekly 90-minute sessions led by trained professionals over 6–7 weeks.

A key takeaway is that self-directed interventions in which participants were responsible for engaging with web-based (Antonson et al. 2018) or audio-based (Zelic 2017; Bartel et al. 2018) mindfulness content or with aromatherapy (K. Hirokawa et al. 2012) on their own schedules following instruction by a trained professional – two of which were brief interventions lasting shorter than a week (Zelic 2017; K. Hirokawa et al. 2012) – failed to show promise for improving sleep in adolescents and young adults. None of these studies observed significant improvements in the study population as a whole. Participants in self-directed interventions that last for longer than one week (Antonson et al. 2018) struggled with adherence.

Some questions regarding the promise of such interventions to improve adolescent sleep remain unanswered following this review. Developmental factors – both neurobiological and social – drive patterns of insufficient sleep across age groups within adolescence, but this review did not identify any patterns of interventions’ effectiveness across early, middle, or late adolescence. The literature shows that adolescents’ sleep worsens with age, specifically on school days, with marked changes at the transition from school settings, such as the transition from middle school to high school (Mitchell et al. 2020), and from secondary school to university settings (Park et al. 2019) and schedules (Stefansdottir et al. 2020). There is also some evidence that mindfulness, the most commonly studied modality in this review, has differential effects across age-groups of adolescents on other outcomes such as executive functioning, and that this may relate to older adolescents’ ability to engage in self-reflection or perspective taking (Dunning et al. 2019). Despite the broad age range for inclusion in this review, this review was unable to examine developmental or age effects. In the studies reviewed here, there is a conflation between intervention setting (e.g. secondary school vs. university) and age: no study in this review included adolescents within the adolescent age group across multiple settings. In addition, no study compared findings across age groups within the study sample: the SENSE study examined moderating effects across gender, but not age (M. J. Blake et al. 2018).

These findings have limited generalizability to improve sleep among adolescents who face a growing problem of poor sleep (Kann et al. 2018). The interventions included predominantly female participants, with minimal reporting on characteristics other than age range and gender. The one study that did report race and ethnicity included a predominantly (81%) non-Hispanic white population. This review yielded no studies that reported meaningful numbers of Black or Latinx adolescents and young adults, despite the fact that there are substantial racial and ethnic disparities in sleep quality among adolescents (Guglielmo et al. 2018; Marczyk Organek et al. 2015; Yip et al. 2020; Matthews et al. 2014). Future studies should consider the inclusion of a more diverse group of participants.

This review intentionally included a wide range of interventions, but was unable to draw conclusions about the relative promise of different mind-body integrative approaches (e.g. comparing mindfulness to qi gong), primarily due to methodological limitations, as has hampered the evidence base of interventions among adults (Neuendorf et al. 2015). Methodological weaknesses in the intervention studies limiting the ability to draw conclusions included the fact that no studies described the long-term effects of the interventions at the time of this review; the studies did not assess what components within the interventions were most effective; and most studies did not assess outcomes objectively, which meant that the studies could not rule out social desirability as a source of measurement error.

This review has some limitations. The authors intentionally chose a scoping review to allow description and characterization of the various mind-body modalities used; the elements of intervention content, setting, delivery format, and intensity; participants in the interventions; and the primary and secondary outcomes assessed using a broad range of experimental and quasi-experimental study designs with the intention of guiding future research. This review purpose made a scoping (rather than a systematic) review an ideal fit (Munn et al. 2018). The intentional inclusion of a broad range to capture the state of the evidence resulted in a heterogeneous mix of studies. While the quality of the evidence was synthesized across domains of quality (study design, outcome assessment and follow-up, quality of intervention implementation, and participants and external validity), this review does not formally evaluate the quality of the evidence using a critical appraisal or risk of bias assessment, as this is not a defining characteristic of a scoping review given the Joanna Briggs Institute manual for evidence synthesis that was used to guide the methods (Peters et al. 2015b). The search process included four databases using broad search terms and hand-review of references, but some articles pertinent to the research question may have been missed.

Despite the limitations in the quality of the underlying studies and the limitations of this study noted above, this review suggests that sleep interventions may improve psychological well-being as an intermediate effect. The relationship between anxiety, depression, stress, and poor sleep is well-established (Bauducco et al. 2016; Alvaro et al. 2013) The effectiveness of mind-body integrative health modalities, particularly mindfulness, in improving stress has been demonstrated among adolescents (Cheng 2016; Lucas-Thompson et al. 2021). Notably, the dimension of sleep quality most improved across these studies was sleep onset latency; there is strong evidence that sleep onset latency particularly affects adolescents with depression, anxiety, or stress (Lovato and Gradisar 2014).

Interventions that can balance providing sufficient intensity with adherence may show promise. In fact, those studies that asked adolescent participants their perspective on the usefulness or perceived effectiveness of the intervention content found a strong correspondence between participants’ perceptions and empirical findings (M. Blake et al. 2017; M. Blake et al. 2016; M. J. Blake et al. 2018; Bartel et al. 2018). Participatory methods in intervention development, engaging adolescents and young adults in the development of culturally appropriate intervention content, format, and intensity, may help in developing interventions that sufficiently engage (Spears et al. 2017) and are of appropriate intensity to impact sleep.

Conclusion

Identifying interventions that can improve adolescents’ sleep is a public health priority. This scoping review synthesized the evidence on mind-body integrative health interventions to improve sleep outcomes in adolescents, from the design and implementation to the reach and observed effects. Reflecting the goal of a scoping review, this inquiry revealed several unanswered questions that should be explored in future intervention research. No interventions described reaching substantial numbers of Black or Latinx adolescents, groups for whom sleep disparities have been identified; nor did any intervention assess developmental stage or age differences, despite documented differences in sleep across age groups of adolescents. While findings were mixed on the efficacy and effectiveness of mind-body integrative health-based interventions in improving sleep outcomes among adolescents, this review identified several promising features of interventions, including using mindfulness, ensuring sufficient intervention dose, and targeting interventions towards adolescents with poor sleep at baseline rather than a general population of adolescents.