Improvements of adolescent psychopathology after insomnia treatment: results from a randomized controlled trial over 1 year.

BACKGROUND: Adolescent insomnia can be treated effectively with cognitive behavioural therapy for insomnia (CBTI). However, little is known about effects of CBTI on psychopathology in adolescents. This study aimed to investigate whether (a) CBTI improves psychopathology in Internet- (IT) and face-to-face group treatment (GT) compared to waitlist (WL), (b) improvement in psychopathology can be attributed to reduced insomnia, (c) improvement in psychopathology remains stable for up to 1 year. METHODS: One hundred and sixteen participants (age = 15.6 years, 25% males) with DSM-5 insomnia, were randomly assigned to IT, GT or WL. CLINICAL TRIAL REGISTRATION: http://www.controlledtrials.com (ISRCTN33922163). Assessments of psychopathology, insomnia and objectively and subjectively measured sleep occurred at baseline, post-treatment, and at 2-, 6- and 12-month follow-up. Multilevel and mediation analyses were run to test hypotheses. The CBTI protocol, 'Sleeping Smart' for both IT and GT consisted of six weekly sessions and a booster session after 2 months. RESULTS: Psychopathology symptoms, insomnia and sleep problems as measured by actigraphy and sleep logs decreased substantially in IT and GT compared with WL at 2-month follow-up with medium to large effect sizes (ESs). Psychopathology symptoms remained stable or further improved for up to 12-month follow-up. ESs at 12-month follow-up for IT and GT were respectively: affective (d = -0.87 and -0.97), anxiety (d = -0.81 for IT), somatic (d = -0.38 and d = -0.52), oppositional (d = -0.42 for GT) and attention deficit hyperactivity disorder (ADHD) problems (d = -0.47 and -0.46). Mediation analyses indicated that reduction of insomnia symptoms after CBTI fully mediated the effects of CBTI on affective and anxiety problems, and partially mediated the effect on ADHD problems. CONCLUSIONS: This is the first study demonstrating that Internet and face-to-face CBT for insomnia achieves long-term reduction in adolescent psychopathology and does so by improving insomnia. This finding can have profound implications for youth mental health care.

Chronic sleep reduction in adolescents-clinical cut-off scores for the Chronic Sleep Reduction Questionnaire (CSRQ).

The Chronic Sleep Reduction Questionnaire is a validated questionnaire that measures symptoms of prolonged insufficient and/or poor sleep and therefore accounts for individuals' sleep need and sleep debt. This study extends its psychometric properties by providing cut-off scores, using a matched sample of 298 healthy adolescents (15.38 ± 1.63 years, 37.9% male, mean Chronic Sleep Reduction Questionnaire score: 32.98 ± 6.51) and 298 adolescents with insomnia/delayed sleep-wake phase disorder (15.48 ± 1.62 years; 37.9% male, mean Chronic Sleep Reduction Questionnaire score: 42.59 ± 7.06). We found an area under the curve of 0.84 (95% confidence interval: 0.81-0.87). Cut-off scores for optimal sensitivity, optimal specificity and based on Youden's criterion are provided. These cut-off scores are highly relevant for use of the Chronic Sleep Reduction Questionnaire in future studies and clinical practice.

Parenting matters: a longitudinal study into parenting and adolescent sleep.

The current three-wave longitudinal study examined the differential relations between general parenting behaviour (monitoring, autonomy granting, and the quality of the parent-adolescent relationship) and adolescent sleep (bedtimes, time in bed, sleep quality and sleepiness) over a period of 2 years. At Time 1, the sample consisted of 650 adolescents between 12 and 15 years old (M = 13.36 years; SD = 0.55 years). At Time 2, 563 adolescents participated, and at Time 3 there were 493 adolescents. The distribution of boys and girls was about equal. Adolescents completed questionnaires in the classroom. Linear mixed model analyses were performed, controlling for sex, age, social economic status and ethnicity. Results showed that higher levels of monitoring contributed to earlier bedtimes, longer time in bed, better sleep quality and less sleepiness. The parent-adolescent relationship quality showed positive associations with time in bed, sleep quality and sleepiness, but not with bedtimes. Autonomy granting appeared hardly to be related to any of the sleep variables. In addition, passing of time, sex and ethnicity contributed to adolescent sleep as main effects or in interaction with parental control and support, suggesting that the main effects of monitoring and the quality of the parent-adolescent relationship are not constant across the whole range of the covariates. Based on the findings of this study, it can be concluded that general parenting behaviour may contribute to better adolescent sleep over time. Therefore, the involvement of parents in improvement of adolescent sleep is highly advocated.

Efficacy of internet and group-administered cognitive behavioral therapy for insomnia in adolescents: a pilot study.

Research indicates that adolescents are at risk for insomnia, but are reluctant to seek help. Treatment of insomnia has been extensively examined in adults, but studies with adolescents are sparse. The purpose of this pilot study was to assess feasibility and efficacy of cognitive behavioral therapy for insomnia (CBT-i) for adolescents in both group and Internet settings. Twenty-six adolescents received 6 weekly sessions of CBT-i in a group (N = 13) or individual Internet setting (N = 13). Their sleep was measured with actigraphy, sleep logs, and questionnaires at baseline, posttreatment, and a 2-month follow up. For both treatments, results show a significant improvement, with medium to large effect sizes (ESs) of sleep onset latency, wake after sleep onset, and sleep efficiency. There was also a small ES increase of total sleep time in sleep log measures, but not in actigraphy measures. On questionnaires measuring symptoms of insomnia and chronic sleep reduction, significant improvements occurred either at posttreatment or at follow up. No differences were found between the groups. This study indicates CBT-i, either in group or in Internet formats, is an effective treatment for insomnia in adolescents. Further studies in a randomized controlled design are warranted.

Adolescents' sleep in low-stress and high-stress (exam) times: a prospective quasi-experiment.

This prospective quasi-experiment (N = 175; mean age = 15.14 years) investigates changes in adolescents' sleep from low-stress (regular school week) to high-stress times (exam week), and examines the (moderating) role of chronic sleep reduction, baseline stress, and gender. Sleep was monitored over three consecutive weeks using actigraphy. Adolescents' sleep was more fragmented during the high-stress time than during the low-stress time, meaning that individuals slept more restless during stressful times. However, sleep efficiency, total sleep time, and sleep onset latency remained stable throughout the three consecutive weeks. High chronic sleep reduction was related to later bedtimes, later sleep start times, later sleep end times, later getting up times, and more time spent in bed. Furthermore, low chronic sleep reduction and high baseline stress levels were related to more fragmented sleep during stressful times. This study shows that stressful times can have negative effects on adolescents' sleep fragmentation, especially for adolescents with low chronic sleep reduction or high baseline stress levels.

Sleep in children with asthma: results of the PIAMA study.

Children with asthma are thought to have impaired sleep quality and quantity. In this study, we investigated which of the many sleep aspects are associated with asthma. Our sample consisted of 2529 children (aged 11 years) who participated in the Prevention and Incidence of Asthma and Mite Allergy (PIAMA) birth cohort study. Parents reported about asthma symptoms (wheezing, dyspnoea, prescription of inhaled corticosteroids and asthma diagnosis) and children reported about different aspects of sleep (bedtime, rise time, sleep quality and daytime sleepiness/tiredness). Results were analysed with (logistic) regression analysis. Children with frequent asthma symptoms significantly more often reported that they felt sleepy or tired during the day (34.4% experienced daytime sleepiness/tiredness at least once a week) than children without asthma symptoms (22.2%) and children with infrequent asthma symptoms (21.9%). This association was not confounded by sex, age of the child, parental educational level or smoking inside the house; the effect was also not modified by sex. There were no associations between asthma and bedtime, time spent in bed or sleep quality. Children with frequent asthma symptoms experienced daytime sleepiness/tiredness more often than children with infrequent or no asthma symptoms. Otherwise, children with asthma did not differ much from children without asthma with regard to sleep.

Parenting and restrictions in childhood epilepsy.

PURPOSE: From the overprotection literature, the predictive and interactional (moderation) effects of controlling and indulgent parenting on restrictions in children with epilepsy were examined. METHODS: Parents of 73 children with epilepsy completed questionnaires on parenting, restrictions, and functional status. Predictive and moderation effects were tested using multiple regression analysis. Moderation was tested with interactive computational methods. RESULTS: Restrictions were significantly (R(2)=.38, FΔ=6.59***, p<.001) predicted from seizure frequency (ß=.24*, p<.05), functional status (ß=-.42***, p<.001), and interaction between controlling and indulgent parenting (ß=.28**, p<.01). Moderation occurred predominantly for high values of control: controlling parents who were not indulgent imposed fewer restrictions. In contrast, controlling parents who were indulgent imposed more restrictions. CONCLUSION: Parents who were controlling and more indulgent imposed more restrictions. Clinicians should ask parents about parenting and restrictions. Future research should examine whether the current study's findings can be replicated.

The Chronic Sleep Reduction Questionnaire (CSRQ): a cross-cultural comparison and validation in Dutch and Australian adolescents.

Although adolescents often experience insufficient and/or poor sleep, sleep variables such as total sleep time do not account for individuals' sleep need and sleep debt and may therefore be an inadequate representation of adolescents' sleep problems and its daytime consequences. This problem can be overcome by using the Chronic Sleep Reduction Questionnaire (CSRQ), an assessment tool that measures symptoms of chronic sleep reduction and therefore accounting for sleep need and sleep debt. The present study aims at developing an English version of the CSRQ and assesses the reliability and validity of the Dutch and the English CSRQ version. The CSRQ was administered in large Dutch (n = 166, age = 15.2 ± 0.57 years, 28% male) and Australian (n = 236, age = 15.5 ± 0.99 years, 65% males) samples. Subjective sleep variables were measured with surveys and sleep diaries of five school nights. Additionally, sleep of the same five nights was monitored with actigraphy. Both CSRQ versions showed good psychometric properties concerning their reliability (Dutch: α = 0.85; English: α = 0.87) and validity as the same overall structure of the two CSRQ versions and significant correlations with subjective and objective sleep variables were found. School grades were related to chronic sleep reduction, whereas the relationship between grades and other sleep variables was weak or absent. These results highlight the idea that chronic sleep reduction may be a better indicator of adolescents' insufficient and/or poor sleep than other sleep variables such as total sleep time.

Risk factors for problem behavior in adolescents of parents with a chronic medical condition.

A wide array of risk factors for problem behavior in adolescents with chronically ill parents emerges from the literature. This study aims to identify those factors with the highest impact on internalizing problem behavior (anxious, depressed and withdrawn behavior, and somatic complaints) and externalizing problem behavior (aggressive and rule-breaking behavior) as measured by the Youth Self-Report (YSR). The YSR was filled in by 160 adolescents (mean age = 15.1 years) from 100 families (102 chronically ill parents and 83 healthy spouses). Linear mixed model analyses were used, enabling separation of variance attributable to individual factors and variance attributable to family membership (i.e., family cluster effect). Predictors were child, parent, illness-related and family characteristics. The results showed that almost half of the variance in internalizing problem scores was explained by family membership, while externalizing problems were mainly explained by individual factors. Roughly 60 % of the variance in internalizing problems was predicted by illness duration, adolescents' feeling of isolation, daily hassles affecting personal life and alienation from the mother. Approximately a third of the variance in externalizing problems was predicted by adolescents' male gender, daily hassles concerning ill parents and alienation from both parents. In conclusion, the variance in adolescent problem behavior is largely accounted for by family membership, children's daily hassles and parent-child attachment. To prevent marginalization of adolescents with a chronically ill parent, it is important to be alert for signs of problem behavior and foster the peer and family support system.

Sleep characteristics across the lifespan in 1.1 million people from the Netherlands, United Kingdom and United States: a systematic review and meta-analysis.

We aimed to obtain reliable reference charts for sleep duration, estimate the prevalence of sleep complaints across the lifespan and identify risk indicators of poor sleep. Studies were identified through systematic literature search in Embase, Medline and Web of Science (9 August 2019) and through personal contacts. Eligible studies had to be published between 2000 and 2017 with data on sleep assessed with questionnaires including ≥100 participants from the general population. We assembled individual participant data from 200,358 people (aged 1-100 years, 55% female) from 36 studies from the Netherlands, 471,759 people (40-69 years, 55.5% female) from the United Kingdom and 409,617 people (≥18 years, 55.8% female) from the United States. One in four people slept less than age-specific recommendations, but only 5.8% slept outside of the 'acceptable' sleep duration. Among teenagers, 51.5% reported total sleep times (TST) of less than the recommended 8-10 h and 18% report daytime sleepiness. In adults (≥18 years), poor sleep quality (13.3%) and insomnia symptoms (9.6-19.4%) were more prevalent than short sleep duration (6.5% with TST < 6 h). Insomnia symptoms were most frequent in people spending ≥9 h in bed, whereas poor sleep quality was more frequent in those spending <6 h in bed. TST was similar across countries, but insomnia symptoms were 1.5-2.9 times higher in the United States. Women (≥41 years) reported sleeping shorter times or slightly less efficiently than men, whereas with actigraphy they were estimated to sleep longer and more efficiently than man. This study provides age- and sex-specific population reference charts for sleep duration and efficiency which can help guide personalized advice on sleep length and preventive practices.

Eye movement desensitization and reprocessing in an adolescent with epilepsy and mild intellectual disability.

Intellectual disability is a comorbid condition in epilepsy. People with epilepsy and intellectual disability are at high risk of developing behavioral problems. Among the many contributors to behavioral problems in people with epilepsy and intellectual disability are those of traumatic experiences. As such, behavioral problems can be seen as a reflection of these traumatic experiences. Among established trauma therapies, eye movement desensitization and reprocessing (EMDR) is an emerging treatment that is effective in adults and also seems to be effective in children. This article is a case report of EMDR in an adolescent with epilepsy and mild intellectual disability, in whom the EMDR children's protocol was used. The aim was to assess whether clinical trauma status significantly diminished to nonclinical status posttreatment. Change in trauma symptoms was evaluated with the Reliable Change Index (RCI). Results showed a significant decrease in trauma symptoms toward nonclinical status from pretreatment to posttreatment. EMDR consequences for epilepsy and intellectual disability are discussed.

Chronic sleep reduction, functioning at school and school achievement in preadolescents.

This study investigates the relationship between chronic sleep reduction, functioning at school and school achievement of boys and girls. To establish individual consequences of chronic sleep reduction (tiredness, sleepiness, loss of energy and emotional instability) the Chronic Sleep Reduction Questionnaire has been developed. A total of 436 children (219 boys, 216 girls, 1 [corrected] missing; mean age = 11 years and 5 months) from the seventh and eight grades of 12 elementary schools participated in this study. The inter-item reliability (Cronbach's alpha = 0.84) and test-retest reliability (r = 0.78) of the Chronic Sleep Reduction Questionnaire were satisfactory. The construct validity of the questionnaire as measured by a confirmative factor analysis was acceptable as well (CMIN/DF = 1.49; CFI = 0.94; RMSEA = 0.034). Cronbach's alpha's of the scales measuring functioning at school (teacher's influence, self-image as pupil, and achievement motivation) were 0.69, 0.86 and 0.79. School achievement was based on self-reported marks concerning six school subjects. To test the models concerning the relations of chronic sleep reduction, functioning at school, and school achievement, the covariance matrix of these variables were analysed by means of structural equation modelling. To test for differences between boys and girls a multi-group model is used. The models representing the relations between chronic sleep reduction - school achievement and chronic sleep reduction - functioning at school - school achievement fitted the data quite well. The impact of chronic sleep reduction on school achievement and functioning at school appeared to be different for boys and girls. Based on the results of this study, it may be concluded that chronic sleep reduction may affect school achievement directly and indirectly via functioning at school, with worse school marks as a consequence.

Contribution of infants' sleep and crying to marital relationship of first-time parent couples in the 1st year after childbirth.

This study investigated the influence of infants' sleep and crying on marital relationship in first-time parent couples (N = 107) during the 1st year after birth. Control variables are parents' insomnia and parental self-efficacy in handling the baby. Questionnaires were administered to both parents before birth, at 2 and 7 weeks after birth, and at 1 year after birth. Results show that marital problem-solving ability did not change but that marital satisfaction diminished significantly over time. Crying was the main child variable that affected marital satisfaction. Fathers' self-efficacy contributed positively to marital problem solving and negatively to paternal insomnia. Both maternal and paternal insomnia affected spouses' insomnia. As infant sleep problems may worsen preexisting parental insomnia, it is recommended that first-time parents be informed about treatments of insomnia.

The impact of online therapeutic feedback on outcome measures in Internet-CBTI for adolescents with insomnia.

BACKGROUND: Guided Internet cognitive behavioral therapy for insomnia (CBTI) offers an effective treatment for adolescents, but little is known about the active ingredients of therapeutic feedback on outcomes. OBJECTIVE: This study aims to identify which factors can be distinguished in written therapeutic feedback in Internet CBTI, and examine whether these factors and participation in a chat session contribute to sleep outcomes. METHODS: Internet CBTI was applied to 57 adolescents (mean age 15.43 years, SD 1.74, 82.5% girls). Symptoms of insomnia and chronic sleep reduction, and total sleep time, time in bed, and sleep efficiency from seven day sleep logs were measured at baseline, post-treatment, and at two month follow-up. With a coding instrument developed for this study, two independent researchers coded transcripts of the written therapeutic feedback of the Internet CBTI sessions with an event sampling method. RESULTS: Principal component analysis of the initial 17 items from the coding instrument yielded four distinct factors of therapeutic feedback, of which only Sleep expertise seemed to contribute to improvements after Internet CBTI. The other factors, indicating forms of encouragement, and participation in a chat session seemed counterproductive. CONCLUSIONS: This first longitudinal study into effects of therapeutic feedback in adolescent Internet CBTI indicated that emphasizing knowledge about sleep might contribute to insomnia improvement. The structured nature of the preprogrammed treatment content, delay of therapeutic feedback due to standardized timing, and unintentional reinforcement of undesirable behavior by giving attention to failures might explain the negative results of encouraging behavior. Further research to identify effective therapeutic factors in Internet therapy is warranted.

Effects of sleep manipulation on cognitive functioning of adolescents: A systematic review.

Adolescents are considered to be at risk for deteriorated cognitive functioning due to insufficient sleep. This systematic review examined the effects of experimental sleep manipulation on adolescent cognitive functioning. Sleep manipulations consisted of total or partial sleep restriction, sleep extension, and sleep improvement. Only articles written in English, with participants' mean age between 10 and 19 y, using objective sleep measures and cognitive performance as outcomes were included. Based on these criteria 16 articles were included. The results showed that the sleep manipulations were successful. Partial sleep restriction had small or no effects on adolescent cognitive functioning. Sleep deprivation studies showed decrements in the psychomotor vigilance task as most consistent finding. Sleep extension and sleep improvement contributed to improvement of working memory. Sleep directly after learning improved memory consolidation. Due to the great diversity of tests and lack of coherent results, decisive conclusions could not be drawn about which domains in particular were influenced by sleep manipulation. Small number of participants, not accounting for the role of sleep quality, individual differences in sleep need, compensatory mechanisms in adolescent sleep and cognitive functioning, and the impurity problem of cognitive tests might explain the absence of more distinct results.

Classical conditioning for preserving the effects of short melatonin treatment in children with delayed sleep: a pilot study.

Melatonin treatment is effective in treating sleep onset problems in children with delayed melatonin onset, but effects usually disappear when treatment is discontinued. In this pilot study, we investigated whether classical conditioning might help in preserving treatment effects of melatonin in children with sleep onset problems, with and without comorbid attention deficit hyperactivity disorder (ADHD) or autism. After a baseline week, 16 children (mean age: 9.92 years, 31% ADHD/autism) received melatonin treatment for 3 weeks and then gradually discontinued the treatment. Classical conditioning was applied by having children drink organic lemonade while taking melatonin and by using a dim red light lamp that was turned on when children went to bed. Results were compared with a group of 41 children (mean age: 9.43 years, 34% ADHD/autism) who received melatonin without classical conditioning. Melatonin treatment was effective in advancing dim light melatonin onset and reducing sleep onset problems, and positive effects were found on health and behavior problems. After stopping melatonin, sleep returned to baseline levels. We found that for children without comorbidity in the experimental group, sleep latency and sleep start delayed less in the stop week, which suggests an effect of classical conditioning. However, classical conditioning seems counterproductive in children with ADHD or autism. Further research is needed to establish these results and to examine other ways to preserve melatonin treatment effects, for example, by applying morning light.

Effects of Melatonin and Bright Light Treatment in Childhood Chronic Sleep Onset Insomnia With Late Melatonin Onset: A Randomized Controlled Study.

Study Objectives: Chronic sleep onset insomnia with late melatonin onset is prevalent in childhood, and has negative daytime consequences. Melatonin treatment is known to be effective in treating these sleep problems. Bright light therapy might be an alternative treatment, with potential advantages over melatonin treatment. In this study, we compare the effects of melatonin and bright light treatment with a placebo condition in children with chronic sleep onset insomnia and late melatonin onset. Methods: Eighty-four children (mean age 10.0 years, 61% boys) first entered a baseline week, after which they received melatonin (N = 26), light (N = 30), or placebo pills (N = 28) for 3 to 4 weeks. Sleep was measured daily with sleep diaries and actigraphy. Before and after treatment children completed a questionnaire on chronic sleep reduction, and Dim Light Melatonin Onset (DLMO) was measured. Results were analyzed with linear mixed model analyses. Results: Melatonin treatment and light therapy decreased sleep latency (sleep diary) and advanced sleep onset (sleep diary and actigraphy), although for sleep onset the effects of melatonin were stronger. In addition, melatonin treatment advanced DLMO and had positive effects on sleep latency and sleep efficiency (actigraphy data), and sleep time (sleep diary and actigraphy data). However, wake after sleep onset (actigraphy) increased with melatonin treatment. No effects on chronic sleep reduction were found. Conclusions: We found positive effects of both melatonin and light treatment on various sleep outcomes, but more and stronger effects were found for melatonin treatment.

The short and long of adolescent sleep: the unique impact of day length.

STUDY OBJECTIVES: Variation in day length is proposed to impact sleep, yet it is unknown whether this is above the influence of behavioural factors. Day length, sleep hygiene, and parent-set bedtime were simultaneously explored, to investigate the relative importance of each on adolescents' sleep. METHODS: An online survey was distributed in four countries at varying latitudes/longitudes (Australia, The Netherlands, Canada, Norway). RESULTS: Overall, 711 (242 male; age M = 15.7 ± 1.6, range = 12-19 yrs) adolescents contributed data. Hierarchical regression analyses showed good sleep hygiene was associated with earlier bedtime, shorter sleep latency, and longer sleep (ß = -0.34; -0.30; 0.32, p < 0.05, respectively). Shorter day length predicted later bedtime (ß = 0.11, p = 0.009), decreased sleep latency (ß = -0.21, p < 0.001), and total sleep (ß = -0.14, p = 0.001). Longer day length predicted earlier bedtimes (ß = -0.11, p = 0.004), and longer sleep (ß = 0.10, p = 0.011). CONCLUSIONS: Sleep hygiene had the most clinical relevance for improving sleep, thus should be considered when implementing adolescent sleep interventions, particularly as small negative effects of shorter day length may be minimised through sleep hygiene techniques.

Cost-Effectiveness of Group and Internet Cognitive Behavioral Therapy for Insomnia in Adolescents: Results from a Randomized Controlled Trial.

STUDY OBJECTIVES: To investigate cost-effectiveness of adolescent cognitive behavioral therapy for insomnia (CBTI) in group- and Internet-delivered formats, from a societal perspective with a time horizon of 1 y. METHODS: Costs and effects data up to 1-y follow-up were obtained from a randomized controlled trial (RCT) comparing Internet CBTI to face-to-face group CBTI. The study was conducted at the laboratory of the Research Institute of Child Development and Education at the University of Amsterdam, and the academic youth mental health care center UvAMinds in Amsterdam. Sixty-two participants meeting Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria for insomnia were randomized to face-to-face group CBTI (GT; n = 31, age = 15.6 y ± 1.8, 71.0% girls) or individual Internet CBTI (IT; n = 31, age = 15.4 y ± 1.5, 83.9% girls). The intervention consisted of six weekly sessions and a 2-mo follow up booster-session of CBTI, consisting of psychoeducation, sleep hygiene, restriction of time in bed, stimulus control, cognitive therapy, and relaxation techniques. GT sessions were held in groups of six to eight adolescents guided by two trained sleep therapists. IT consisted of individual Internet therapy with preprogrammed content similar to GT, and guided by trained sleep therapists. RESULTS: Outcome measures were subjective sleep efficiency (SE) ≥ 85%, and quality-adjusted life-years (QALY). Analyses were conducted from a societal perspective. Incremental cost-effectiveness ratios (ICERs) were calculated using bootstrap sampling, and presented in cost-effectiveness planes. Primary analysis showed costs over 1 y were higher for GT but effects were similar for IT and GT. Bootstrapped ICERs demonstrated there is a high probability of IT being cost-effective compared to GT. Secondary analyses confirmed robustness of results. CONCLUSIONS: Internet CBTI is a cost-effective treatment compared to group CBTI for adolescents, although effects were largely similar for both formats. Further studies in a clinical setting are warranted. CLINICAL TRIAL REGISTRATION: ID: ISRCTN33922163; trial name: Effectiveness of cognitive behavioral therapy for sleeplessness in adolescents; URL: http://www.isrctn.com/ISRCTN33922163.

The effects of light therapy on sleep problems: A systematic review and meta-analysis.

Although bright light therapy seems a promising treatment for sleep problems, research shows inconclusive results. This meta-analysis is the first to systematically review the effect of light therapy on sleep problems in general and on specific types of sleep problems in particular (circadian rhythm sleep disorders, insomnia, sleep problems related to Alzheimer's disease and dementia). Fifty-three studies with a total of 1154 participants were included. Overall effects and effects on separate circadian and sleep outcomes were examined. We calculated Hedges' g effect sizes and we investigated the effects of twelve moderators (design-related, treatment-related, participant-related). Light therapy was found effective in the treatment of sleep problems in general (g = 0.39), and for circadian rhythm sleep disorders (g = 0.41), insomnia (g = 0.47), and sleep problems related to Alzheimer's disease/dementia (g = 0.30) specifically. For circadian rhythm sleep disorders, effects were smaller for randomised controlled trials. For insomnia, we found larger effects for studies using a higher light intensity, and for sleep problems related to Alzheimer's disease/dementia larger effects were found for studies with more female participants. There was indication of publication bias. To conclude, light therapy is effective for sleep problems in general, particularly for circadian outcomes and insomnia symptoms. However, most effect sizes are small to medium.