Wolfson 2015

Sleep Health xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

Sleep Health
Journal of the National Sleep Foundation

journal homepage: http://www.elsevier.com/locate/sleh
Original Research
Effects of the Young Adolescent Sleep Smart Program on sleep hygiene

practices, sleep health efficacy, and behavioral well-being☆,☆☆
Amy R. Wolfson, PhD a,1, Elizabeth Harkins, BA a,⁎, Michaela Johnson, BA a, Christine Marco, PhD b
a
Department of Psychology, College of the Holy Cross, 1 College Street, Worcester, MA 01610
b
Department of Psychology, Rhode Island College, 600 Mount Pleasant Avenue, Horace Mann Hall, Providence, RI 02908
a r t i c l e i n f o a b s t r a c t
Article history: Objectives: Using a social learning model, the aim of the Sleep Smart Program was to primarily improve sleep
Received 3 June 2015 health behaviors and secondarily improve academic performance and behavioral well-being.
Received in revised form 6 July 2015 Design: Randomized control trial for a social learning-based preventive intervention program.
Accepted 6 July 2015 Participants: A diverse group of seventh graders from 2 urban, middle schools were randomly assigned, ac-
Available online xxxx
cording to school, to an 8-session Sleep Smart Program (SS = 70) or a comparison group (comparison = 73).
Measurements: Sleep patterns, sleep hygiene, and sleep health efficacy; academic performance; and behavioral
Keywords:
Adolescence
well-being were assessed at 4 times of measure (baseline, postintervention, 2 follow-up times in eighth grade).
Intervention Results: SS seventh graders experienced significantly greater sleep health efficacy, improved physiological and
Sleep hygiene emotional sleep hygiene, more time in bed, and earlier bedtimes vs comparison group. SS (vs comparison) par-
Sleep-health efficacy ticipants also reported a significant decrease in internalizing behavior problems and sustained academic perfor-
mance. Finally, although not maintained at time 4, SS participants continued to report improved sleep health
efficacy at time 3, whereas the comparison group participants' sleep health efficacy declined.
Conclusion: The Sleep Smart preventive intervention was effective in improving sleep health efficacy, sleep
hygiene, time in bed, and bedtimes; in maintaining grades; and in reducing internalizing behavior problems,
yet these changes were not sustained at follow-up.
© 2015 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
Introduction School schedules, extracurricular hours, and other environmental

constraints are not beneficial to middle school– and high school–
Over the last 30 years, researchers, educators, and health care pro- aged adolescents' sleep schedules and requirements. 5,8,14,15 In fact,
viders have recognized early adolescence as a developmental time over the course of early to late adolescence, teens develop a sleep
that is unique and distinct from late childhood and later adolescence, debt by getting a minimal amount of sleep on school nights and
usually defined as ages 10 to 15 years.1,2 In particular, a nuanced un- then delaying, as well as oversleeping, on weekends.3,5,14,15 The re-
derstanding of adolescents' sleep requirements, schedules, and regu- sult is that even early adolescents are frequently absent or late for
latory processes has emerged. 3 -7 Laboratory and self-report data school, sleepy and moody during school hours, inattentive during
have demonstrated that adolescents sleep need of about 9 hours class time, and struggle academically.14,16-18 Furthermore, early ado-
does not change from ages 10 to 17 years and, with the onset of pu- lescents with poor sleep hygiene practices such as consuming caf-
berty, they experience a circadian phase delay. 3-5,8,9 feine close to BT and/or engaging in physiologically arousing
Despite this stable or increased need, studies indicate that as early activities (eg, cell phone use, playing video/iPad games) report later
as age 12 (ie, sixth or seventh grade), adolescents obtain less sleep, BTs, more disturbed sleep throughout the night, and increased day-
experience increased daytime sleepiness, and report poor sleep hy- time sleepiness.10,19-23 A recent systematic literature review concluded
giene, including using greater amounts of caffeine close to bedtime that studies consistently report a significant association between
(BT) and engaging in screen-based activities that delay sleep. 10 -13 screen time and reduced sleep duration and increased sleep problems
for children and adolescents.10 Similarly, a recent meta-analysis docu-
☆ Sleep-Smart curriculum materials are available upon request from the first author. mented that good sleep hygiene (eg, regular BTs, decreased technology
☆☆ Conflict of interest: All authors report that there are no competing financial interests use) and physical activity function as protective factors, largely under
regarding this paper. adolescents' control, and are associated with earlier BTs for 12- to 18-
⁎ Corresponding author at: 313 S Broadway St, Unit 5, Baltimore, MD 21231.
year-olds.23 In comparison, a negative home environment and evening
E-mail address: [email protected] (E. Harkins).
1
Present Address: Amy R. Wolfson, Loyola University Maryland, 4501 North Charles light, which is less likely to be under early adolescents' control,
Street, Baltimore, MD 21210 lead to later BTs. Despite the resounding agreement among health
http://dx.doi.org/10.1016/j.sleh.2015.07.002
2352-7218/© 2015 National Sleep Foundation. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Wolfson AR, et al, Effects of the Young Adolescent Sleep Smart Program on sleep hygiene practices, sleep health
efficacy, and behavioral well-being, Sleep Health (2015), http://dx.doi.org/10.1016/j.sleh.2015.07.002
2 A.R. Wolfson et al. / Sleep Health xxx (2015) xxx–xxx
professionals that health habits need to be taught early in life,23-25 only theory: informative instructions, participatory classroom activities
some school districts have started to include sleep hygiene as part of (eg, role playing, age-appropriate games), personal goal setting (uti-
their numerous health education standards (eg, California, Michigan, lization of sleep goal charts and diaries), feedback, and reinforcement
and Virginia). 26-28 It is unclear, however, as to whether the focus is (relevant rewards and specific recommendations each session). The
on teaching about sleep health vs working with adolescents to change program used some of the social learning aspects of the Slice of Life
their sleep health behaviors. program, designed to promote healthy eating and physical activity
An increasing number of sleep education programs have been de- patterns for adolescents 34, as well as the Great Sensations Program.35
veloped with the aim of improving adolescents' sleep practices by pro- Students who participated in the Slice of Life program reported a sig-
viding knowledge on the importance of sleep and strategies by which nificant improvement in knowledge and awareness regarding their
this change can be achieved. Cortesi et al29 evaluated the effects of a eating habits and increased appropriate exercising. 34 Similarly, the
2-hour sleep educational program on a sample of Italian high school Great Sensations Program, a nutrition-education project, was effec-
students. The targeted students and a comparison group were evaluat- tive in decreasing consumption of salty snacks and in increasing the
ed using a sleep knowledge test before the program, immediately after consumption of target or healthy snack foods. 35 The studies' out-
the program, and during a 3-month follow-up to assess the comes suggested that school programs developed using social learn-
intervention's effectiveness. Both groups had poor baseline knowledge ing principles can be effective in facilitating important behavior
of sleep; but compared with the control group, the sleep education changes for early adolescents. In addition, some aspects of the SS
group showed an average 50% gain in the number of correct answers were influenced by the skill training model by Botvin et al,36 which
immediately after the course and good retention of information three provides adolescents with the necessary knowledge, skills, and
months later. De Sousa et al 30 evaluated the effects of a 1-week personal sleep health efficacy for resisting social influences to
school-based sleep hygiene program on sleep quality and daytime smoke or, in this case, drink caffeine and/or stay up late.
sleepiness in a small sample of high school–aged students in Brazil. Thus, it was hypothesized that students who participated in the pro-
Participants showed improved sleep-wake schedules and shorter gram (SS) would obtain more sleep, develop better physiological sleep
sleep latencies reflecting promising behavioral changes; however, hygiene practices, and report a greater sense of efficacy regarding their
sleep quality and daytime sleepiness did not improve. sleep habits than a comparison group that did not participate in the pro-
Moseley and Gradisar31 developed a school-based sleep interven- gram. In addition, it was hypothesized that those in the SS group might
tion program for high school–aged adolescents using a cognitive- perform better academically and evidence fewer behavioral problems.
behavioral therapy framework with four 50-minute classes over a
4-week period. To evaluate the program's effectiveness, a randomized
Methods
controlled trial featured 2 groups (program class and control group)
assessed at 3 time points. Moseley and Gradisar's31 program success-
Study design and participants
fully increased sleep knowledge; however, compared to the control
group, sleep patterns did not improve. In a follow-up study, the re-
Seventh graders and their parents were recruited to participate
searchers evaluated a motivational-based school intervention for im-
from health classes in 2 urban, New England, public middle schools
proving adolescents' sleep. 32 Again, the intervention group (vs
with delayed school start times of 8:37 AM. The schools were random-
control) increased their sleep knowledge and their motivation to reg-
ly assigned to either the SS or the comparison conditions before fam-
ularize their sleep schedules. Although the adolescents in the
ilies were recruited for the study, with condition assigned by school
motivation-oriented program did not improve their sleep patterns or
rather than by individual classrooms to avoid cross-classroom con-
daytime functioning, the program participants showed a marked re-
tamination. Of approximately 300 seventh graders in 12 health clas-
tention rate in sustained sleep knowledge, which may be a precursor
ses across the 2 schools, 48% (143 seventh graders) consented to
to behavioral change. More recently, they evaluated school-based
participate (parental consent, seventh grader assent). There was a
sleep education programs using adjunct bright light therapy and/or pa-
100% retention rate between times 1 and 2, whereas some partici-
rental involvement within a motivational interviewing framework.33
pants left the study at times 3 and 4 largely due to leaving the school
Contrary to their earlier studies, students reported decreased sleep
or the district (Ns reported in Figure). Of note, of those participants
onset latency and better mood ratings in addition to improved
who left the study between times 2 and 3 or 3 and 4, there were no
sleep knowledge in comparison to the control group. At a 6-week
significant differences on any of the dependent variables. Participant
follow-up, improved sleep knowledge, mood, and decreased sleep
characteristics are displayed in Table 1.
onset latency were maintained. Nonetheless, bright light devices and
parental involvement did not enhance the adolescents' behavioral
changes, and it is not clear if the high school–aged participants main- Procedures
tained their knowledge or sleep changes beyond 6 weeks.
Taken together, these programs illustrate possible avenues to de- After November recruitment, baseline (time 1) assessment oc-
creasing sleep restriction, improving sleep hygiene, and subsequent curred during January of seventh grade for both the SS and compari-
behavioral consequences for adolescents and demonstrate the value son group participants. Then, during February to March, students in
in raising healthy sleep-related behaviors for older adolescents. Few the SS condition participated in the 4-week (8 total sessions, twice
studies, however, have evaluated the effectiveness of sleep health a week) sleep hygiene program held at the same time and length as
programs for early adolescents.31-33 their regularly scheduled health class (ie, 40 minutes). Postsession
The current study examined the efficacy of the Sleep Smart Pro- (time 2) assessments for the SS and comparison groups took place
gram (SS), a school-based sleep hygiene education program for im- 1-week after the end of the program. Sleep Smart booster sessions
proving early adolescents' sleep health efficacy, sleep hygiene were held to review and reinforce the sleep smart strategies taught
practices, and patterns to ultimately improve academic performance in the initial 8 sessions. The first booster session was held in May of
and behavioral well-being. The program assumes 3-way dynamic in- seventh grade with the time 3 follow-up assessment for both groups
teraction among personal/developmental factors (eg, sleep need), in October to November of eighth grade. The second booster session
environmental influences (eg, sleep arrangements), and behavior was held in February of eighth grade with the time 4 follow-up as-
(eg, caffeine, screen use). It was developed based on social learning sessment in April/May of eighth grade. Attendance for the 8 initial
A.R. Wolfson et al. / Sleep Health xxx (2015) xxx–xxx 3
Group Sleep Smart Comparison ing healthy sleep hygiene practices and obtaining sufficient sleep.
Session-specific topics are summarized in Table 2. SS leaders used goal
setting, modeling, role playing, educational games, and self-
monitoring throughout the program, and the participants received
Time 1 n = 73 n = 70
session-relevant rewards after each session (eg, water bottle for caffeine
session, laminated, wallet-size cards with sleep hygiene principles,
sleep-smart pen to record their BT/wake time [WT]). SS participants'
Time 2 n = 73 n = 70 parents received a weekly newsletter that reviewed session information
so that parents could reinforce the Sleep Smart strategies.
The comparison condition was described as research on the de-
velopment of adolescents' sleep patterns and largely controlled for
Time 3 n = 64 n = 66 contact with the participants. This group met for approximately 30-
40 minutes for each of their 4 sessions. Researchers maintained con-
tact with comparison participants and their parents or guardians over
Time 4 n = 60 n = 64 the same period as the SS group through telephone follow-up. These
points of contact focused on observing and reporting sleep patterns at
Figure. Ns across the program.
the time 1 and time 2 assessments and did not approach ways to im-
prove current sleep habits. Comparison group participants, like SS
participants, completed all measures during the school day.
Measures
sessions and the 4 booster sessions was 100%, excluding participants
who were no longer in the study for times 3 and 4. At each time point, Background variables
participants completed the same set of measures to assess sleep time, Parents/guardians provided information about family income on
sleep hygiene, behavior problems, pubertal status, and self-efficacy, the background information form. Income was measured with a
described in more detail in the Measures section. SS and comparison checklist of dollar ranges reflecting $10,000 increments, and parents
participants and their parents were given gift cards for participating marked the option that included their total household income.
in the study. Because of low frequency of responses in some options, responses
were coded into 3 ordinal levels: lower income (b$30,000), middle
Sleep smart curriculum income ($30,000-$60,000), and higher income (N$60,000).38 Partici-
pants reported their race/ethnicity along with height and weight on
Students in the SS condition learned about healthy sleep behaviors a revised School Sleep Habits Questionnaire. Based on this informa-
through a preventive health curriculum, which sought to improve spe- tion, body mass index (BMI) was calculated using the Center for
cific sleep practices. Participants met in small groups (9-11 students) Disease Control recommended BMI for age, which takes into account
cofacilitated by 2 trained, BA-level leaders (supervised by a licensed age and sex. 14,39 Pubertal status was measured with the child's
clinical psychologist) over the eight 40-minute sessions. In an effort to self-ratings on the Pubertal Development Scale, 9,40 which yields a
monitor treatment fidelity, each group had the same 2 co-leaders for categorical classification of pubertal status (eg, prepubertal, early,
all 8 sessions, and only 4 pairs of co-facilitators taught the sessions mid, late, and postpubertal).
over the course of the study. Seventh graders were provided with didac-
Table 2
tic information on adolescent sleep and specific strategies for establish-
Sleep Smart session specific topics.
Session Topic Session content

Table 1 number
Participant characteristics. 1 What is sleep? Why is it Sleep quiz, education on sleep
important? The basics cycles, and sleep needs for
Comparison, Sleep Smart,
adolescents
n = 73 n = 70
2 Learn “Cool” sleep habits Red/green light game, role playing
Age 12.58 (0.48) 12.50 (0.56) to learn healthy sleep habits, and
Sex 43 f. 30 m 42 f. 28 m hygiene
a
Family income⁎⁎⁎ 3 Where and how much sleep is Importance of sufficient sleep (8.5-
b$30,000 21 (30%) 28 (45%) in your schedule? 9.5 h/night) for daytime
a
Race/ethnicity 28b (38%) 42c (64%) functioning, exercise/game to
(% underrepresented minority)⁎ reinforce
Pubertal status 4 Consistent sleep/wake cycles Emphasis on consistent sleep-wake
Pre/early 17 (23%) 12 (18%) habits, hygiene; relay race to
Mid 30 (41%) 22 (33%) review/reinforce hygiene strategies
Late/post 27 (36%) 32 (48%) 5 BT routines Skits created to role play helpful BT
BMI⁎⁎ M = 19.83 (4.32) M = 23.46 (5.78) routines
Overweight 5 (7%) 15 (22%) 6 Monitoring sleep patterns and Learn to self-assess/monitor sleep
sleep health efficacy for patterns through graphing activity
⁎ P ≤ .05.
obtaining goals
⁎⁎ P ≤ .01.
7 Effects of caffeine Caffeine education, observations of
⁎⁎⁎ P ≤ .001.
a caffeine advertising, creation of ads
Race/ethnicity characteristics of the participants in each school are similar to the
to promote healthy, noncaffeinated
district data for the 2 schools; however, 38% of the students' families at the comparison
drinks
school vs 53% at the Sleep Smart school met the criteria for low income, defined as
8 Wrap up: review, evaluation, Review 8 sessions and goal setting
meeting the criteria for free or reduced lunch.37
b and sleep smart
Comparison: 4% Black/African American, 20% Hispanic, 7% Asian, 7% multiracial.
c commencement
Sleep Smart: 15% Black/African American, 33% Hispanic, 8% Asian, 8% multiracial.
Sleep outcome variables somewhat/sometimes true; 2, very true/often true) of how truly
Using Bandura's concept of self-efficacy and the recommenda- each behavior reflected the adolescent's behavior. Lower scores indi-
tions for developing self-efficacy scales, sleep health efficacy was cate better well-being. Analyses are based on the YSR, as cross-
measured using the situation-specific measure, Adolescent Health informant correlations for the YSR and CBCL were .33 for internaliz-
and Sleep Efficacy Scale. 41-43 The scale consisted of 6 sleep hygiene ing and .46 for externalizing, similar to other studies.48
behaviors (eg, establishing healthy bed routine, getting at least 8.5
hours, healthy sleep habits, avoiding energetic activities, avoiding Statistical analyses
caffeine, establishing regular BT schedule), jointly considered to mea-
sure sleep health efficacy, or one's potential competency in their abil- The analyses presented here focus on changes from baseline (T1)
ity to make changes to these referenced behaviors (ie, sleep health). to each postintervention time point (T2, T3, and T4). For all post-
Participants rated each sleep-related question according to how intervention outcome or dependent variables, difference scores
sure they were that they could handle each activity using 100-point were calculated separately for each follow-up using T1 as the refer-
% scale.41-43 Cronbach α for the 6 sleep items was .84 for the 2 pilot ence point. Four multivariate analyses of covariance (MANCOVA)
samples taken before this program41,42 and .83 for the current study. were conducted to assess the effects of the program on the adoles-
Sleep hygiene was examined using the Adolescent Sleep Hygiene cents' changes in sleep health efficacy; sleep hygiene practices;
Scale, a 28-item self-report measure that assesses sleep-facilitating school and weekend night BT, WT, and TIB; academic performance;
and sleep-inhibiting practices in 12- to 18-year-old adolescents and behavioral well-being. An initial MANCOVA assessed the
along different conceptual domains. 21,44 Six domains were focused program's effect on itemized sleep health efficacy. A second
on for this study: physiological (5 items), cognitive (6 items), emo- MANCOVA evaluated the changes in 6 sleep hygiene domains, BT
tional (3 items), sleep environment (4 items), BT routine (1 item), screen use, and PM caffeine use. A third MANCOVA assessed differences
and sleep stability (4 items). For example, the physiological domain in school and weekend night sleep patterns, specifically, BT, WT, and
queries about frequency of behaviors relating to exercise, activity be- TIB. A final MANCOVA assessed the secondary effects of the program
fore BT, and feelings of hunger (after 6:00 in the evening, I have drinks on internalizing and externalizing problem behaviors and academic
with caffeine; during the hour before bedtime, I am very active; during performance based on English and Math grades. Covariates for each
the 1 hour before bedtime, I drink more than 4 glasses of water; I go to model included background variables (family income, BMI, pubertal
bed with a stomach ache; I go to bed feeling hungry) and the emotional status, race/ethnicity, and sex) and the T1 dependent variables.
domain looks at frequency of behaviors tied to strong or upsetting
emotions before BT. Participants reported how often these sleep- Results
related behaviors occurred during the past month along a 6-point
scale (“always,” “frequently-if not always,” “quite often,” “some- Background characteristics
times,” “once in a while,” and “never”), with higher scores indicative
of better sleep hygiene. Reliability estimates of internal consistency As shown in Table 1, significant differences between conditions
for the subscales ranged from Cronbach α of .60 to .82. were noted at baseline in income, race/ethnicity, BMI, and pubertal
School and weekend night BT and wake time (WT) were reported status, with SS participants from families with lower incomes
on the revised School Sleep Habits Questionnaire (adapted from (b$30,000/year), further along in pubertal development, and more
Wolfson and Carskadon 14), which asks about usual sleep and wake overweight/obese than comparison participants. As previously men-
behaviors over the past 2 weeks (ie, what time do you usually go to tioned, these variables were controlled for in all analyses.
bed/wake up?). School and weekend night time in bed (TIB) were
calculated by using the self-report BT and WT for school and Sleep health efficacy, sleep hygiene, and sleep-wake patterns
weekend nights.
PM Caffeine use (caffeine consumption from noon until BT), an- Pearson correlations were examined for the sleep variables. Sleep
other aspect of sleep hygiene, was assessed based on the participants' health efficacy and school night sleep patterns (BT and TIB) were
self-reported afternoon/evening caffeine use (type and amount) on a significantly correlated (rs = 0.18-0.23; Ps b .04). Likewise, earlier
daily sleep-wake diary. Total caffeine consumption was summed to weekend WTs were associated with higher sleep health efficacy
get total daily caffeine use (milligrams per ounce). Afternoon and (rs = −0.19 to −0.21; Ps b .04). Lower caffeine and screen use were
evening caffeine use was assessed, as previous studies suggest that associated with higher sleep health efficacy for avoiding caffeine and
dose-dependent caffeine use close to BT negatively affects sleep avoiding energetic activities (rs = −0.17 to −0.21; Ps b .05). Further-
maintenance in adults and adolescents.45,46 more, the 6 different sleep hygiene domains were also significantly cor-
Bedtime screen time use (eg, television, video games, and com- related with sleep health efficacy (rs = 0.26-0.38; Ps b .01).
puter) was calculated based on the participants' self-reported screen Table 3 displays the difference scores, means, and SDs for the
time use in the hour before bed (reported in minutes). sleep health efficacy variables for T1 and T2. The SS prompted signif-
icant changes in sleep health efficacy (multivariate F (6, 135) = 2.42;
Academic performance and behavioral outcome variables P = .03) as explained by univariate differences in 5 of 6 sleep health
Average English grades and average Math grades were based on efficacy items (avoiding energetic activities was not significant). SS
students' school transcripts, which were reported on a 100-point participants reported an improvement in their sleep health efficacy
grading scale. Transcripts from quarters 2 and 3 corresponded to ac- over BT-specific behaviors. In addition, the SS participants main-
ademic performance for time 1 and time 2, respectively. English and tained overall sleep health efficacy from time 1 to time 3 (F (6, 77)
Math grades were used as an indication of academic performance, = 2.29; P = .04). This significance is explained entirely by the partic-
with higher scores indicating better academic performance. Behav- ipants' sleep health efficacy that they can obtain at least 8.5 hours of
ioral well-being was assessed using the Internalizing and Externaliz- sleep each night. The SS participants reported increased percentage
ing Behavior Problem scores, derived from the Youth Self Report of sleep health efficacy from T1 to T3 (62%-64%), whereas the
(YSR) and the parent report Child Behavior Checklist (internalizing comparison group participants reported decreased sleep health
and externalizing behavior problem scales). 47 The scores are based efficacy percentage (73%-57%). This difference was not significant
on the 112 items, each rated on a 3-point scale (0, not true; 1, from T1 to T4.
Table 3
Means and SDs for sleep health efficacy variables at time 1, time 2, and difference scores.
Sleep health efficacy Condition DS T1 T2
Healthy bed routine⁎ Sleep Smart group M (SD) .10 (.39) .51 (.30) .62 (.28)
Comparison group M (SD) −.02 (.31) .61 (.32) .59 (.35)
At least 8.5 hours⁎⁎ Sleep Smart group M (SD) .06 (.35) .63 (.32) .69 (.31)
Healthy sleep habits⁎ Sleep Smart group M (SD) .04 (.28) .63 (.28) .67 (.27)
Avoid energetic activities Sleep Smart group M (SD) .04 (.37) .33 (.32) .37 (.34)
Avoid caffeine⁎⁎ Sleep Smart group M (SD) .09 (.45) .46 (.34) .55 (.36)
Regular BT schedule⁎⁎ Sleep Smart group M (SD) .10 (.39) .59 (.31) .68 (.27)
Abbreviation: DS, difference score from T1 to T2.

Note: Variables represent how participants rated each sleep health efficacy question according to how sure they were that they could handle each behavior on 100% scale. This
difference was not significant from T1 to T4.
⁎ P ≤ .05.
⁎⁎ P ≤ .01.
As seen in Table 4, overall, SS group participants significantly im- significantly earlier BTs for the SS vs comparison participants (school
proved their sleep hygiene practices as compared to the comparison night BT, P = .013; weekend night BT, P = .008), whereas WTs did
group, multivariate F (8, 87) = 2.82; P = .05. Specifically, SS partici- not change for the 2 groups from T1 to T2 and there were no signifi-
pants decreased BT screen use by nearly 5 minutes, whereas the com- cant differences reported from T1 to T3 and from T1 to T4 for any of
parison group increased BT screen use by over 6 minutes (P = .07); these sleep pattern variables.
SS participants decreased PM caffeine use by 8.80 mg/oz, whereas
comparison group only decreased caffeine use by 2.39 mg/oz (P =
.02); and SS participants improved physiological and emotional Academic performance and behavioral well-being
sleep hygiene scores by 0.53 and 0.43, respectively, whereas compar-
ison group improved by less than 0.20 (Ps ≤ .05). There were no sig- Table 6 displays the difference scores, means, and SDs for the SS
nificant differences reported from T1 to T3 and from T1 to T4. and comparison groups' transcript reported English and Math grades
Overall, SS participants reported increased TIB and earlier BTs on and internalizing and externalizing behavior problem scores.
school and weekend nights (multivariate F (3, 94) = 3.31; P = Behavioral well-being and academic performance significantly
.005) relative to their comparison peers (see Table 5). On average, changed with the SS, multivariate F (4, 83) = 2.71; P = .036. Univar-
participants reported a 13-minute increase in school night TIB, iate analyses revealed that the SS vs comparison participants report-
whereas their comparison group peers reported a 12-minute de- ed a moderately significant decrease in internalizing behavior
crease in school night TIB (P = .034). In addition on weekends, SS problems (P = .06). In addition, SS participants maintained their
participants reported that they were getting 42 more minutes in English academic performance from quarters 2 to 3 (ie, times corre-
bed, whereas the comparison group reported that they decreased sponding to before and after the Sleep Smart intervention), whereas
their weekend night TIB by 17 minutes (P = .009). Increased TIB on the comparison participants experienced a significant decline in their
school and weekend nights for the SS group corresponded with academic performance based on average English course grades
Table 4
Means and SDs for sleep hygiene variables at time 1, time 2, and difference scores.
Sleep hygiene Condition DS T1 T2
Physiological⁎⁎⁎ Sleep Smart M (SD) 0.50 (0.83) 4.04 (0.75) 4.54 (0.77)
Comparison M (SD) 0.20 (0.75) 4.17 (0.99) 4.37 (0.84)
Cognitive Sleep Smart M (SD) 0.29 (0.91) 3.81 (0.94) 4.12 (0.98)
Comparison M (SD) 0.18 (1.14) 3.85 (1.13) 4.03 (1.11)
Emotional⁎ Sleep Smart M (SD) 0.43 (1.04) 4.71 (1.05) 5.14 (0.88)
Comparison M (SD) 0.16 (1.14) 4.94 (1.07) 5.11 (1.03)
Sleep environment Sleep Smart M (SD) 0.37(1.15) 4.69 (1.07) 5.06 (0.90)
Comparison M (SD) 0.20 (1.02) 5.00 (1.13) 5.16 (0.99)
BT routine Sleep Smart M (SD) 0.13 (2.20) 3.37 (1.75) 3.52 (1.63)
Comparison M (SD) 0.08 (1.94) 3.63 (1.96) 3.71 (1.84)
Sleep stability Sleep Smart M (SD) 0.57 (1.35) 3.42 (1.22) 4.00 (1.15)
Comparison M (SD) 0.45 (1.07) 3.41 (1.17) 3.86 (1.11)
PM Caffeine use (mg/oz)⁎ Sleep Smart M (SD) −8.80 (16.05) 13.49 (15.78) 4.89 (8.52)
Comparison M (SD) −2.39 (10.25) 8.09 (12.13) 5.92 (12.20)
BT screen time (min)⁎⁎ Sleep Smart M (SD) −4.91 (26.55) 33.41 (21.32) 28.01 (21.06)
Comparison M (SD) 6.48 (19.18) 20.27 (18.78) 26.91 (20.13)
Note: Physiological, cognitive, emotional, sleep environment, daytime sleepiness, BT routine, and sleep stability: variables from Adolescent Sleep Hygiene Scale. PM Caffeine use
was based on participants' self-reported afternoon/evening caffeine use (milligrams per ounce) on sleep-wake diary. BT screen time use (eg, television, video games, computer)
calculated based on participants' self-reported screen time use in hour before bed (minutes). No significant differences reported from T1 to T3 or T1 to T4 for these variables.
⁎ P ≤ .10.
⁎⁎ P ≤ .05.
⁎⁎⁎ P ≤ .01.
Table 5
Means and SDs for school and weekend sleep pattern variables at time 1 and time 2 and difference scores.
TIB Condition DS (min) T1 T2
School night TIB⁎ Sleep Smart group M (SD) 13 (58) 8.98 (67) 9.20 (55)
Comparison group M (SD) −12 (43) 9.43 (54) 9.23 (51)
Weekend TIB (min)⁎⁎ Sleep Smart group M (SD) 42 (133) 9.80 (126) 10.50 (174)
Comparison group M (SD) −17 (95) 10.50 (107) 10.22 (96)
School BT (hour:min)⁎⁎ Sleep Smart group M (SD) −0:12 (0:55) 21:56 (1:10) 21:44 (0:55)
Comparison group M (SD) 0:11 (0:38) 21:28 (0:54) 21:39 (0:47)
School WT (hour:min) Sleep Smart group M (SD) −0:01 (0:20) 6:53 (0:26) 6:52 (0:25)
Comparison group M (SD) −0:09 (0:35) 6.55 (0:34) 6:46 (0:43)
Weekend BT (hour:min)⁎⁎ Sleep Smart group M (SD) −0:58 (1:38) 24:12 (1:58) 23:20 (1:34)
Comparison group M (SD) −0:03 (1:02) 23:22 (1:29) 23.25 (1:28)
Weekend WT (hour:min) Sleep Smart group M (SD) −0:10 (1:51) 9:59 (1:57) 9:49 (1:50)
Comparison group M (SD) −0:14 (1:15) 9:51 (1:48) 9:37 (1:44)

Note: School and weekend wake and bed times were reported on the School Sleep Habits Questionnaire. School and weekend night TIB was computed using self-reported school and
weekend night BT and WT. There were no significant differences reported from T1 to T3 or from T1 to T4 for these variables.
⁎ P ≤ .05.
⁎⁎ P ≤ .01.
showing minimal decline in English grade (P = .04). There were no demonstrate that the program helped adolescents develop a greater
significant differences from T1 to T3 and from T1 to T4. sense of efficacy in their ability to manage aspects of their sleep. In
particular, 5 of the 6 sleep health efficacy behaviors changed signifi-
Discussion cantly from time 1 to time 2, suggesting that SS adolescents acknowl-
edged that they were more efficacious post-program from baseline in
The purpose of this study was to evaluate the impact of the SS on their ability to establish a BT routine, maintain a regular sleep sched-
early adolescents' sleep patterns and hygiene, including caffeine use, ule, monitor their sleep habits, and decrease their caffeine use. More-
along with academic and behavioral well-being. Findings demon- over, sleep health efficacy was significantly associated with healthier
strate that this preventive intervention was effective in helping the sleep patterns and hygiene practices and the early adolescents who
seventh graders in an urban school environment feel more compe- participated in the SS maintained their self-efficacy regarding their
tent in their ability to manage certain aspects of their sleep habits; es- ability to obtain at least 8.5 hours of sleep each night from time 1 to
tablish better sleep hygiene practices; increase school and weekend time 3 in comparison to their peers who reported decreased sleep
TIB, advance BTs, particularly weekend nights; and use less caffeine health efficacy on the same variable, suggesting that improving
in comparison to their peers who did not participate in the program. one's sleep health efficacy might be linked to improving sleep habits
With regard to sleep patterns, it is particularly noteworthy that the SS and hygiene. The aspects of the adolescents' sleep that changed after
early adolescents reported that they were going to bed almost an the program were topics that were centrally focused on throughout
hour earlier on weekend nights after the intervention, whereas the program such as caffeine use, quantity of sleep, and sleep hygiene
their peers had more delayed BTs. practices. It should be noted, however, that a causal relationship
Clinical significance is also important in a preventive intervention cannot be established and that other models of behavior exist.
study. For adolescents, studies have shown for example that adoles- Other explanations suggest that adolescents may alter their
cents who get As and Bs obtain at least 20 minutes more sleep and/ behaviors even when they are not necessarily connected to primary
or go to bed 20 minutes earlier than their peers who are performing changes in efficacy, including motivational, self-regulation, or other
poorly in school.13,14 Therefore, from a clinical perspective, it is note- cognitive-behavioral change models. 50,51
worthy that the SS adolescents reported an average increase of 13 mi- Stability in academic performance for the SS group suggests that
nutes school night and 42 minutes weekend night sleep after gains from the program may have helped to maintain academic
the intervention. performance, as the SS participants' grades were consistent over the
Based on the social learning model, the SS focused on sleep health academic year, whereas their comparison group peers' grades wors-
efficacy along with sleep patterns and sleep hygiene practices as a ened. During the time 2 assessment, participants were well into
model for promoting behavioral change in adolescents. 49 Results their third quarter of seventh grade, which should have allowed for
Table 6
Means and SDs for academic performance and behavioral well-being outcome variables at time 1, time 2, and difference scores.
Outcome variables Condition DS T1 T2
Average English grade⁎⁎ (100%) Sleep Smart group M (SD) 0.05 (13.81) 78.10 (14.82) 78.15 (14.40)
Comparison group M (SD) −6.10 (12.51) 84.56 (10.64) 78.68 (16.75)
Average Math grade (100%) Sleep Smart group M (SD) 0.65 (8.03) 80.17 (13.68) 80.83 (10.71)
YSR—internalizing behavior⁎ Sleep Smart group M (SD) −3.72 (11.38) 52.56 (9.20) 49.03 (8.24)
YSR—externalizing behavior Sleep Smart group M (SD) −0.77 (6.88) 50.82 (9.00) 50.12 (9.00)

Note: Average English grades were based on student transcripts, which were reported on a 100-point grading scale. Behavioral well-being was assessed using internalizing and
externalizing behavior problem scores, derived from the YSR. There were no significant differences reported from T1 to T3 or T1 to T4 for these variables.
⁎ P ≤ .10.
⁎⁎ P ≤ .05.
adjustment to the school year and workload. Comparing the SS Conclusion

groups' consistent academic performance vs the comparison adoles-
cents' declining academic performance suggests that cumulative Findings suggest that this social learning–based program focused
sleep loss might negatively affect grades, whereas the tools learned on sleep patterns and sleep hygiene has clear potential for successful-
in the SS may have helped to buffer the young adolescents against ly helping early adolescents in an urban school environment improve
the risk of academic difficulties over the first year of middle school.13 their sleep health efficacy and change and maintain important sleep
Although we are encouraged by our findings, certain caveats and behaviors and academic performance. In particular, the Sleep Smart
limitations pertain. The schools were randomly assigned as SS or preventive intervention was effective in: improving sleep health effi-
comparison; however, baseline differences between the groups may cacy, sleep hygiene, TIB, and BTs; maintaining grades; and reducing
have affected the program. SS adolescents came from lower income internalizing behavior problems; yet, these changes were not
families, had higher BMIs, and were further along in pubertal devel- sustained at follow-up.
opment. The evident socioeconomic disadvantage of the SS group
may have created stressful environments that negatively impacted Acknowledgements
sleep health. 52 In addition, increased BMI is associated with less
sleep and more sleep problems in adolescents. 53 Finally, more ad- This research was funded by the following grant: NIH, NICH5, 5
vanced pubertal development is often associated with a delayed R01 HD047928-06 from the National Institutes of Health and con-
sleep phase preference. 9 After controlling for baseline differences, ducted while the first author was at the Department of Psychology,
however, the intervention was still effective in improving sleep be- College of the Holy Cross, Worcester, MA. The authors wish to
haviors for SS participants, suggesting that without these baseline dif- thank the many research assistants, including Michaela Sparling,
ferences, the effects may have been even greater. Moreover, the Andrea Azuaje, Kelly Naku, Kathleen Barry, Christina Kyriakos, Jillian
contact with the comparison participants, although not purposefully Canton, Melissa Richards, and Marissa Lown.
educational, may have highlighted important aspects of sleep with-
out overtly addressing these issues. For example, although the com-
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Sleep Health xxx (2015) xxx–xxx

Contents lists available at ScienceDirect

journal homepage: http://www.elsevier.com/locate/sleh

Effects of the Young Adolescent Sleep Smart Program on sleep hygiene

Introduction School schedules, extracurricular hours, and other environmental

Session Topic Session content

Sleep health efﬁcacy Condition DS T1 T2

Abbreviation: DS, difference score from T1 to T2.

Sleep hygiene Condition DS T1 T2

TIB Condition DS (min) T1 T2

Abbreviation: DS, difference score from T1 to T2.

Outcome variables Condition DS T1 T2

Abbreviation: DS, difference score from T1 to T2.

adjustment to the school year and workload. Comparing the SS Conclusion

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