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Further Evidence for the JuSt Program as Treatment for Insomnia in Adolescents: Results from a 1-Year Follow-Up Study

Published Online:https://doi.org/10.5664/jcsm.5496Cited by:18

ABSTRACT

Study Objectives:

Insomnia in adolescence adversely affects young people's current and future functioning, as well as their mental and physical health. Thus, effective and economic treatment is invaluable. The present study evaluated a 6-session multimodal group therapy, JuSt, for adolescents suffering from insomnia including cognitive-behavioral elements and clinical hypnosis.

Methods:

Participants (n = 19, 68.4% female) were aged 11–16 years and suffered from insomnia. Sleep onset latency (SOL), time spent awake time after sleep onset (WASO), and sleep efficiency (SE) were measured with sleep logs before and after treatment, and at 3-, 6-, and 12-month follow-up.

Results:

Compared to baseline, SOL and WASO significantly decreased, while there was a significant increase in SE and the feeling of being rested after the JuSt treatment. At 12-month follow-up, all parameters were still significantly different from their baseline level. The long-term effect sizes were at least as large as the short-term effects, indicating a stable improvement.

Conclusions:

These results suggest that the JuSt program represents a potent intervention to sustainably reduce insomniac complaints in adolescents. Given the unselected nature of our sample, a broad indication can be assumed. To further evaluate the program's efficacy, randomized controlled trials should be conducted.

Citation:

Roeser K, Schwerdtle B, Kübler A, Schlarb AA. Further evidence for the just program as treatment for insomnia in adolescents: results from a 1-year follow-up study. J Clin Sleep Med 2016;12(2):257–262.

INTRODUCTION

Adolescence is characterized by developmental processes that cause physical, mental, and social changes in young people's lives. Also their sleep is subject to developmental processes, which cause a decrease in sleep duration as well as in sleep depth1,2 and a delay in the sleep-wake-rhythm.3,4 Psychosocial changes, e.g., peer activities in the evening or at night and less parental influence on sleep timing, also contribute to alterations in adolescents' sleep behavior.5,6 Taken together, all these aspects cause sleep to become shorter, lighter, and later during the course of puberty.7 While this process itself is not harmful, it may, however, facilitate the manifestation of sleep problems, especially insomnia.810

According to the third edition of the International Classification of Sleep Disorders (ICSD), insomnia is characterized by difficulties initiating or maintaining sleep, waking up too early, or complaints about poor sleep quality.11 These problems occur despite adequate opportunity and circumstances for sleep and are accompanied by daytime impairments, such as daytime sleepiness, mood disturbance, or attention deficits. In a study by Johnson and colleagues,12 lifetime prevalence of insomnia in adolescents aged 13 to 16 years was 10.7%. Other studies on adolescents report point prevalence rates between 4 and 6.6%.1315 Insomnia symptoms in adolescence often become chronic14,16,17 and adversely affect various outcome measures, including school performance, social functioning, and mental health, especially anxiety disorders and depression, but also aggressive behavior and suicidality.1619 Since sleep problems in adolescents put both an immediate and a long-ranging threat on young people's development, effective interventions that target sleep disorders at an early stage are necessary.

BRIEF SUMMARY

Current Knowledge/Study Rationale: Insomnia in adolescence adversely affects young people's mental and physical health. The present study evaluated a multimodal group therapy by which insomnia in adolescents can be treated effectively and economically.

Study Impact: The intervention reduced symptoms of insomnia and improvements were stable for a 12 months follow-up history. Thus, the JuSt treatment constitutes an effective and economic intervention that can be implemented by clinical psychologists and psychotherapists.

A promising approach to treat adolescents with insomnia has been developed by Schlarb, who adapted therapeutic strategies that have proven effective in adult sleep therapy to a multimodal treatment, “JuSt,” addressing adolescents with insomnia between 11 and 17 years of age.20,21 The JuSt treatment comprises 6 weekly sessions for groups of 4–8 adolescent patients.1 Five sessions take place with the adolescents, while one session is conducted for their parents. The therapeutic components of the JuSt are psychoeducation about sleep and its disorders, behavioral strategies such as sleep hygiene and stimulus control, cognitive therapy addressing rumination and dysfunctional cognitions, guided imagery to foster relaxation, and clinical hypnosis.22 By combining multiple psychotherapeutic elements, this treatment exceeds the existing approaches to improve adolescent sleep. Most previous studies have focused on preventively educating adolescents about sleep.2325 Thereby, adolescents' knowledge about sleep can be enlarged23,24; however, this does not necessarily result in modified sleep behavior or improved sleep quality.2527 Others have focused on special populations, such as adolescents with intellectual disabilities28 or substance abuse.29 The JuSt, in contrast, takes a therapeutic rather than a preventive approach. In a pilot study, Schlarb and colleagues22 evaluated the treatment's acceptance and short-term outcome in 18 adolescents with insomnia and their parents who both accepted the intervention well. As compared to before treatment, sleep log data showed a significant reduction in sleep onset latency (SOL), and an increase in sleep efficiency (SE), i.e., sleep time in relation to time spent in bed, after treatment. Moreover, the first results suggest that the treatment's positive effects remain stable for a follow-up history of 3 months.30 However, this study focused on internal validity and, therefore, adolescents with additional mental disorders were excluded.

The aims of the present study were firstly, to replicate the results of JuSt22,30; secondly, to provide evidence for the treatment's external validity by including adolescents with comorbid mental disorders; and thirdly, to include a follow-up history of 12 months to assess long-term effects. Thus, for the current study, we hypothesized that (1) after participating in the JuSt, insomnia symptoms would improve in an adolescent sample with and without comorbid mental disorders. Furthermore, we expected (2) improvement in participants' sleep to be still evident at a 1-year follow-up measurement.

METHODS

Information about the JuSt treatment was available on the university's homepage and in local newspapers. Brochures about the program were distributed to schools, pediatricians, youth centers, and other institutions addressing adolescents in and around Würzburg, Germany. Adolescents were included in the treatment if they were between 11 and 17 years of age and had symptoms of insomnia as defined by the ICSD11 for at least 3 months. Participants with insomnia and comorbid mental disorders, e.g., attention deficit hyperactivity disorder (ADHD), were also included. The JuSt treatment was administrated according to the structured treatment manuals.20,21 Treatment administration and diagnostic procedures were performed by KR, BS, and trained student assistants. Adolescents and their parents gave written informed consent to participate in the JuSt treatment and the diagnostic procedure. They did not receive financial compensation. The study was conducted in accordance with standard ethical guidelines as defined by the Declaration of Helsinki and approved by the ethical review committee at the University of Würzburg.

Participants and Procedure

We implemented a pre-post study design with participants undergoing 5 occasions of measurement. During the first diagnostic appointment (t1), sleep-related diagnoses were examined using the ICSD, and adolescents' medical history were assessed to identify comorbid mental disorders. One week after treatment, adolescents completed the post-measurement (t2). Follow-up measurements were conducted 3 (t3), 6 (t4), and 12 months (t5) after treatment. At each time of measurement, participants completed several diagnostic instruments, including sleep logs, from which the outcome variables of the present study were derived (see below). A total of n = 23 adolescents participated; 4 had to be excluded, because they did not provide sleep log data at all times of measurement due to reasons indicated in Figure 1. None of them had a comorbid mental disorder. Thus, the following analyses are based on n = 19 adolescents aged 11–16 years (mean = 13.55, standard deviation ± 1.75, n = 13 [68.4%] female), who completed the treatment and provided sleep logs at all times of measurement (Figure 1). To evaluate possible effects of waiting, n = 8 participants had been assessed twice before treatment (t0) at an interval of 3 months on average.

Figure 1: Study procedure and sample sizes for each time of measurement.

Note that the missings indicated for each time of measurement result in a listwise valid sample size of n = 19 participants.

Sleep Logs

At each time of measurement, participants completed sleep logs for a 2-week period. The second week's data were analyzed to allow participants a 1-week adaptation phase to get used to handling the sleep logs. Only in exceptional cases, such as illness or school holidays during the second week, we analyzed the first week's data. We used the sleep logs to calculate, in minutes per day, mean SOL and mean time spent awake during the night (wake after sleep onset [WASO]). The sleep logs also asked participants to indicate how rested they felt after awaking, using a visual analogue scale from 1 to 6, with lower scores reflecting feeling more rested (FR). We used SE as an additional outcome variable (SE = total sleep time / total time in bed × 100).

Data Analysis

All analyses were conducted with IBM SPSS Statistics 19. Due to the relatively small sample size, we applied nonparametric tests, i.e., the Friedman test for detecting differences across the multiple times of measurement, and the Wilcoxon test for comparing two repeated measurements. In case of a significant Friedman test, we conducted 2 post hoc tests to test our hypotheses about short- and long-term effects of the JuSt treatment. Short-term effects were analyzed by comparing the baseline (t1) to post measurement (t2). Regarding the long-term effects, we compared t1 to 12-month follow-up (t5). According to our hypotheses, we expected significant differences in both comparisons. Since we had directional hypotheses, one-tailed p values are reported. The level of statistical significance was set at p ≤ 0.05. For significant differences between 2 times of measurement, effect sizes (dCohen) were calculated and interpreted in sensu Cohen.31

RESULTS

At first, we analyzed the subsample of n = 8 participants who had been assessed twice before the beginning of the JuSt treatment (see Participants and Procedure). In this group, neither sleep-related diagnoses nor any of the study's outcome measures had changed significantly between the 2 pre-assessments (SOL: Z = −0.70, ns; WASO: Z = −0.94, ns; SE: Z = −0.84, ns; RS: Z = −0.93, ns). Thus, data from the immediate assessment before treatment (t1) were considered the baseline for all participants.

Diagnoses

Prevalence rates of participants' sleep-related diagnoses according to the ICSD are shown in Table 1. In the total sample, insomnia was the main sleep-related diagnosis. In n = 13 (68.4%) adolescents, one or more secondary sleep-related diagnoses were present (see Table 1). None of the participants was taking sleep medication. Comorbid mental disorders were present in n = 7 (36.8%) participants. Four of them had been previously diagnosed with ADHD, two participants reported symptoms of obsessive-compulsive disorder, and one had a history of posttraumatic stress disorder. Of these participants, 3 were taking psychotropic medication (methylphenidate), which was maintained during the study procedure. Means and standard deviations of the study variables are shown in Table 2.

Table 1 Sleep-related main and secondary diagnoses.

Table 1

Table 2 Means and standard deviations of the study variables.

Table 2

Sleep Onset Latency (SOL)

Adolescents' sleep log data showed a significant reduction in SOL during the 12-month study period (χ2(4) = 24.05, p < 0.001, see Figure 2A). Post hoc comparisons revealed a significant reduction from before (t1) to after treatment (t2, Z = −1.73, p = 0.042) with a small effect of dCohen = −0.30. Comparing t1 to t5 also yielded a significant result (Z = −3.76, p < 0.001). With dCohen = −1.01, the size of this effect was large.

Figure 2
Figure 2

(A) Mean sleep onset latency (SOL) in minutes per day, (B) mean wake after sleep onset (WASO) in minutes per day, (C) feeling rested (FR, lower scores indicate better restauration), and (D) sleep efficiency (SE) in percent per day, in the course of the 12-month study period. Error bars indicate standard error. t1: pre, t2: post; t3: 3-month follow-up, t4: 6-month follow-up, t5: 12-month follow-up

Wake after Sleep Onset (WASO)

The Friedman-test showed a significant reduction in WASO during the 12-month study period (χ2(4) = 13.22, p = 0.005, see Figure 2B). Significant differences emerged in the post hoc comparisons between t1 and both t2 (Z = −2.70, p = 0.004), and t5 (Z = −2.67, p = 0.004), with intermediate effects of dCohen = −0.62 and −0.64, respectively.

Feeling Rested (FR)

The Friedman-test revealed significant improvement in FR during the 12-month study period (χ2(4) = 14.24, p = 0.004, see Figure 2C). In the post hoc comparisons, significant differences emerged between t1 and both t2 (Z = −2.28, p = 0.012) and t5 (Z = −2.62, p = 0.005) with small (dCohen = −0.40) and intermediate (dCohen = −0.60) effects, respectively.

Sleep Efficiency (SE)

During the 12-month study period, SE significantly improved (χ2(4) = 24.63, p < 0.001, see Figure 2D). From t1 to t2, SE significantly increased (Z = −2.13, p = 0.017), resulting in an intermediate effect of dCohen = 0.55). The difference between t1 and the 12-months follow-up was also significant (Z = −3.10, p = 0.001), with a large effect of dCohen = 0.88.

DISCUSSION

In the present study, we could demonstrate stable effects of the JuSt treatment, a 6-session multimodal group treatment by Schlarb,20,21 on several sleep parameters in adolescents with insomnia between 11 and 17 years of age. Adolescence is characterized by age-specific developmental tasks, and therefore, adapting therapeutic strategies to the target age-group is mandatory. Previous studies on sleep therapy in toddlers32 and primary school aged children33 suggest that age-specific approaches lead to promising results. With the current study, we sought to investigate if this was also true for adolescence. Therefore, the aim of the present study was to provide further evidence for the short-term and long-term effects of the JuSt treatment using a pre-post study design. Compared to baseline before treatment (t1), the sleep parameters characterizing insomnia, namely SOL, WASO, and FR had significantly improved at post measurement (t2). Thus, after participating in the JuSt treatment, adolescents fell asleep faster, spent less time being wake during the night, and felt more refreshed after awaking. SE also significantly increased between pre and post measurement. These improvements were still measureable 12 months after the treatment. The effect sizes for the improvement in WASO were medium in the short- and in the long-term comparison. Thus, this effect remained stable during our 12-months study period. Regarding SOL, FR and SE, effect sizes were small to intermediate for the short-term and intermediate to large in the long-term comparison. Not only did these effects remain stable over time, they even gained in strength after treatment. As evident from Figure 2, SOL, RS, and SE improved until 3-month follow-up and stabilized on this level for the rest of the follow-up history. A possible explanation might be that, given the relative shortness of the intervention, some therapeutic strategies continued to have a sleep-improving effect even after the six sessions were completed.

Previous findings about the benefits of the JuSt treatment have been presented.22,30 The current study extends the knowledge about the JuSt treatment in three aspects: Firstly, we were able to replicate the positive impact of the treatment on participants' ability to initiate and maintain sleep and on sleep quality. Thus, the JuSt treatment turned out to be effective independent of the therapist (AS was neither involved in recruitment nor in treatment and primary data analysis). This is of course essential for its implementation in clinical practice. Thus, our results imply that, in the future, clinical psychologists and psychotherapists will be able to successfully integrate the JuSt treatment. As our sample included participants with comorbid mental disorders, conditions that practitioners often face in their clinical routine,28,29 our results indicate external validity of the intervention. This suggests that the JuSt treatment represents a promising and, given the good retention rate, a well-accepted intervention even in heterogeneous adolescent populations. Finally, the follow-up history of 12 months demonstrated long-term stability of the treatment effects. Previous educational or preventive studies on adolescent sleep report a follow-up history of six weeks at most23,25,27; thus, our study goes well beyond previous assessments.

However, our results are limited by the pre-post design, and future research should compare the treatment's effects to an active control group that includes supportive counseling. By implementing a dismantling approach, additive and/or synergetic effects of the treatment's multimodal conception could be analyzed. In addition to self-report data, sleep parameter should be assessed using objective approaches, such as actigraphy, polysomnography, or even new apps, for example the sleep cycle alarm clock ( http://www.sleepcycle.com/), if this method will prove reliable. Different settings should be evaluated, such as in- and outpatient treatment to investigate whether JuSt can be implemented into clinical routine. Future studies should include larger sample sizes and subgroup analysis, for example regarding the influence of ADHD and ADHD medication on treatment outcome. Furthermore, prospective studies should be conducted to investigate whether the JuSt treatment in adolescence can decrease the incidence of chronic insomnia in adults and prevent adverse effects on psychosocial functioning and health.16

To conclude, a short-term intervention with elements of psycho-education and cognitive behavioral and hypnotic therapy reduces symptoms of behavioral insomnia. These improvements are stable over time and retention rates are good. The significant and sustainable improvement in the sleep of our unselected sample with heterogeneous diagnoses, suggests a broad indication of the JuSt treatment. Thus, the JuSt treatment constitutes an effective and economic intervention that can be implemented by clinical psychologists and psychotherapists.

DISCLOSURE STATEMENT

This was not an industry supported study. The authors have indicated no financial conflicts of interest.

ABBREVIATIONS

ADHD

attention deficit hyperactivity disorder

FR

feeling rested

ICSD

International Classification of Sleep Disorders

JuSt

Adolescent Sleep Training (Jugendlichen-Schlaftraining)

SE

sleep efficiency

SOL

sleep onset latency

WASO

wake after sleep onset

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