Sleep in young people: What works now and where to? A meta-review of behavioural and cognitive interventions and lifestyle factors

Figures & data

Table 1. Description of the reviews examining factors affecting sleep and sleep interventions in young people, included in this meta-review.

	Review paper	n = papers	n = total sample	Sample details	Type of studies included	Type of disorder/disruption	Factors associated with sleep & Tx components	Length of interventions	Mode of interventions	Sleep outcomes
	Systematic reviews
1	Hale & Guan (2015). Sleep Med Rev., 21, 50–58	67 (35 in adolescents)	549,454	Subsample (n = 298,733) of adolescents and young adults (11–25 years)	Cohort studies; Cross-sectional studies	Poor sleep quality and/or quantity	Screen time and devices	No intervention	No intervention	Sleep timing; Sleep duration; Sleep quality; SOL; Daytime tiredness or sleepiness; Insomnia symptoms
4	Hall & Nethery (2019). Paediatr. Respir. Rev., 31, 64–74	44 (10 in adolescents)	282,615	Subsample (n = 109,081) of adolescents (13–18 years).	Exploratory trials (7); Intervention (3) studies	Poor sleep; Sleep hygiene	Sleep education; modifying technology exposure and/or environmental factors (e.g., passive smoking, school commute times); milk drinks to promote sleep	≥1 session	Group; Individual; Individual with parent; Individual with parents and teachers	Sleep duration; Sleep quality; Sleep onset
	Meta-analyses
5	Aslund et al. (2018). Clin Sleep Med., 14, (11), 1937–47	6	528	School aged children and adolescents; M age = 14.6 yrs; female = 63%)	RCT	Poor sleep	Cognitive and behavioral sleep interventions	≥4 × 1 hr Tx sessions	Group; Individual; Internet	TST; SOL
3	Mei et al ((2018)). Sleep Sci. Prac.; 2:9	19	253,904	School aged young adults, M age, 14.82 years; 51.1% male)	Clinical trials; Cohort studies; Cross-sectional studies	Poor sleep quality and/or quantity	Electronic media use	No intervention	No intervention	SOL; WASO; TST
2	Carter et al. (2016). JAMA Pediatr, E1–7.	20	125,198	School aged children and adolescents (6–19 years); M age = 14.6 yrs	Clinical trials; Cohort studies; Cross-sectional studies	Poor sleep quality and/or quantity	Portable screen-based media devices	No intervention	No intervention	Sleep quantity; Sleep quality; EDS.
6	McLay et al. (2020). J. Behav. Educ.	10 (3 in adolescents)	893	Subsample of adolescents (n = 162; M age = 17.7 yrs; female = 70.4%)	Intervention; RCT (1)	Sleep problems; Insomnia	Telehealth Interventions; CBT based	2 × 1 hr group/individual workshops + follow-up telehealth contact	Individual; Group; Parent led/supported	SOL; Night wakenings; TST; other-nighttime events
7	Blake et al. (2017). Clin. Child Fam. Psychol. Rev., 20, 227–49	9	357	Adolescents (M age = 15.0 yrs; female = 61.7%)	Intervention; RCTs (4)	Insomnia; poor sleep.	CBT based	≥4 × 1 hr treatment sessions	Group; Individual; Individual with parent; Parent education sessions	Subjective quality; TST; SE; WASO; SOL.
8	Chung et al., (2017). J Sch Health, 87, 401–8	7	1,876	Adolescents (M age = 14.7 yrs; female = 61.0%)	Intervention: RCT; Cluster RT	Short sleep	School-based sleep education programs	≥4 × 50-minute classes	Group	TST; SOL; Mood
9	Bartel et al. (2015). Sleep Med. Rev., 21, 72e85	41	85,561	Young adults 11–20 yrs	Correlational; cohort studies	Sleep disruption	Protective and risk factors for adolescent sleep;	No intervention	No intervention	SOL, TST; Self-reported sleep.
10	Olds et al. (2010). Sleep Med. Rev., 14, 371–78.	30	92,977	Sample of adolescents (11–18 yrs)	Correlational; cohort studies	Sleep patterns	Factors associated with time in bed	No intervention	No intervention	Sex, age, geographical region and day type interact and predict sleep patterns.
11	Gradisar et al. (2011). Sleep Med., 12, 110–18	41	371,758	Sample of adolescents (11–18 yrs)	Correlational; cohort studies	Sleep patterns	Factors associated with time in bed	No intervention	No intervention	Cultural factors, day type, and age interact to impact sleep pattern.
12	Niu et al. (2021). Sleep Med. Rev., 58, 101443.	17 (7 in adolescents M = 14.9 & 10 in young adults M = 21.7)	605	Sample of adolescents-young adults (13–30 yrs)	Intervention	Low sleep quantity	Behavioral sleep intervention	5–49 nights (41% of studies conducted over 7-days)	Extend sleep opportunity; reduce screen access; Prevent naps; Reduce caffeine consumption, and; Provide sleep education.	SE; Sleep quality; EDS

Note: Tx = Treatment; yrs = years’ SOL = Sleep Onset Latency; WASO = Wake After Sleep Onset; TST = Total Sleep Time; EDS = Excessive Daytime Sleepiness.

Table 2. List of lifestyle/associated factors affecting sleep quality and quantity as grouped across the reviews and the average effect size across reviews.

Factor affecting	# Reviews (article #)	Description and possible mechanisms	Key findings	Recommendations and future directions resulting from the included paper/s*
Electronic media use	5 (1;2;3;4;9)	Impact of use of electronic devices with screens, particularly in the evening, including television, computers, gaming, mobile devices, and unspecified screens on sleep. Possible causal pathways: Exposure to blue wave length light emissions. Exciting or stressful information creating cognitive and/or emotional arousal. Lack of parental or personal boundaries around social media/device use established, or could be indicative of family boundaries more extensively. Difficulty sleeping may lead to increased evening screen use.	Screen time is adversely associated with sleep outcomes: Primarily shortened duration, delayed timing, and reports of excessive daytime somnolence. It is unclear what the causal pathway is and the direction of the relationship between screens and sleep problems.	Youth should be advised to limit or reduce screen time use, particularly during the hours before bed Whether light from screen devices impacts sleep is equivocal. Research into causal pathways needs to be conducted.
Type of day	2 (9;10)	The type of day (work or school day vs. weekend/holiday) impacts sleep. Possible causal pathways: Societal pressures and expectations, e.g., meeting deadlines, joining events at predefined times, and school start times curtailing sleep duration.	The type of day impacts regularizing wake and bed times: Generally, individuals sleep longer on weekends/holidays.	Youth should be advised to regularize their sleep schedule, particularly keeping a regular wake time. Education explaining that: Daytime pressures may impact sleep regularity, and; That school start times are incompatible with young adult circadian drives, May be important information for sleep hygiene in young adults.
Sex	1 (10)	Biological sex or gender identity impact sleep. Possible causal pathways: Hormones. Societal expectations.	Females appear to have greater TST than males.	Information on how gendered norms or biological sex factors impact sleep could be delivered in the course of sleep hygiene. Research into causal pathways needs to be conducted.
Age	2 (10;11)	Age impacts sleep. Possible causal pathways: Biological need for sleep declines with age. Ability to maintain sleep declines with age. Social and work/education demands increase with age. Circadian timing delays in adolescence and young adults.	Sleep appears to decline with age: -14 mins/school day per year of age increase. -7 mins/non-school day per year of age increase.	Youth should be provided information on how age can impact sleep routines. Research into causal pathways needed.
Culture/Geographical location	4 (4;9;10;11)	Cultural practices impact sleep and the view of importance of sleep vs. other activities. Possible causal pathways: Societal norms and expectations, e.g., prioritizing socializing and education over sleep. Geographically different day and night lengths may impact the environmental cues for sleep and wake.	Cultural practices such as norms and expectations, for example around achievement, substance use, impact sleep length, e.g., Turkish adolescents exposed to passive smoking and who drink caffeinated drinks report shorter sleep than peers who abstain. Individuals living in Asiatic countries sleep on average 40-60 min less than individuals living in predominantly European countries.	Youth and parents/housemates should be informed that cultural practices and environmental cues (e.g., amount of sunlight) may impact sleep routines. Research into causal pathways is needed.
Substance use	2 (4;9)	Substance use by self or others in living environment impacts sleep. Possible causal pathways: Substances impact sleep through chemical pathways Substance use may be a marker of prioritizing other activities over sleep, e.g., use of alcohol, coffee, or smoking may indicate a group prioritization of socializing late at night.	Use of substances impacts sleep duration. Use of caffeine is associated with shorter sleep duration. Sleeping in environments where passive smoking occurs shortens sleep duration.	Youth and parents/housemates should be informed that substance use and timing of use can impact sleep duration. Research into causal pathways needs to be conducted.
Family environment and sleep boundaries	2 (7;9)	Establishing sleep boundaries and family routines impacts sleep. Possible causal pathways: Normalization of establishing family/personal boundaries for sleep and sleep routines. Understanding of the importance of sleep and the need for regularity. “Permission” from a perceived expert to establish sleep boundaries for self or family.	Establishing a safe sleep environment, with regularized routines, appears to be associated with better sleep.	Youth should be informed that regularizing sleep time is important for sleep quality. Families should be educated in how to create “safe sleep environments”, establish sleep routines, and set sleep boundaries, e.g., bedtimes, family time together in the evening, and/or limiting technology use in the hours before bed. Research into causal pathways is necessary.
Evening light exposure	1 (9)	Determining if evening light exposure from technological devices impacts sleep. Possible causal pathways: Light in the blue wavelength alters internal clocks and sleep timing.	Evening light exposure does appear to: Delay bedtime, and is; Associated with a shorter sleep duration. It does not appear to be associated with: Delayed sleep onset.	Youth should be informed that while light exposure can impact sleep, it is as yet unknown if the amount and type of light from devices, or the cognitive and emotional arousal of the types of activities, e.g., social media and gaming, impact sleep. Research into causal pathways is necessary.
Exercise and extracurricular activities	1 (9)	Generally increasing the amount and type, and/or timing of exercise to promote greater sleep amount and quality. Possible causal pathways: Physical and cognitive exertion increase demand for sleep through biological (buildup of metabolites) or psychological (sense of satisfaction with ones’ day) means. Exercise may act as an external zeitgeber for sleep and wake timings.	Exercise is: Beneficial for bedtimes, but; Does not appear to impact sleep onset latency or total sleep time.	Youth should be advised that exercise is associated with keeping a regular bedtime. Research into causal pathways is necessary.
Sleep hygiene education programs	2 (4;8)	Education is provided on the importance and purpose of sleep, what healthy sleep looks and feels like, and the average guidelines of “good sleep” for certain age ranges and genders. This also includes definitions, signs, and symptoms of sleep disorders. Possible causal pathways: Information allows an individual to notice areas for improvement, challenge social norms, and/or understand the biological need for sleep.	Sleep education programs yield equivocal results as to their impact on sleep onset and/or duration.	It is unclear if sleep-based education programs are useful: Utility may be increased if school-based programs follow-up with telehealth sessions that individualize the program (as done in brief CBT group interventions), or if school-wide changes are made that match student sleep timings, e.g., delayed-school start times. Mood may be improved through sleep education programs. However, further research is required on how to modify school-based programs to improve effectiveness.
Cognitive behavioral interventions	3 (5;6;7)	Young people are encouraged to identify and challenge unhelpful thoughts, beliefs, and behaviors concerning sleep. Ultimately the aim is to reduce negative emotion and cognitive arousal, and strengthen the association between bed and sleep by restricting the types of activities that can be conducted in bed and standardizing routines and sleep times around bed in order to create a consolidated sleep period. Possible causal pathways: Greater quantity of sleep Better quality of sleep Greater consistency of sleep timing Perceived better sleep	CBT interventions of 2+ face-to-face sessions, with phone or telehealth follow-up, had a positive impact on sleep: Where objective TST did increase (Range: +11.47 to 16.15 min) Where SOL did decrease (−9.31 to 16.15 min) Where objective SE did improve (+2.82%) Typically, individuals overestimated how much their sleep objectively improved, e.g., 16 minutes on actigraphy vs 30 minutes by self-report. Improvements for SE and TST appear to be maintained over time. Not all studies where participants noted improved sleep also recorded improvements in measurable sleep measures, e.g., TST/SOL. Improvements in self- and/or parent-reported sleep quality Where the first 2 sessions were delivered in a face-to-face and group format, the follow-up phone sessions aimed to personalize the general sleep advice provided in the group sessions.	CBT techniques can be useful in a youth population for improving objective sleep amount and self-perceived sleep quality and regularity. Improvements in timing or amount of sleep appear to be small (11–16 minutes), suggesting quality or self-perception of sleep, not quantity, may be more important when examining sleep satisfaction and daytime achievement. Improvements in sleep appear to also result in improvements in mood and anxiety symptoms. Research in causal pathways is necessary.
Sleep opportunity	1 (12)	Young people are provided with at-home sleep education and agreed upon bedtimes that increase the sleep opportunity by 1–1.5 hours. Greater quantity of sleep Sleep quality improves Greater consistency of sleep timing Perceived better sleep Sleep education and rules are established Reduced access to technology at bedtime reduces bedtime procrastination Imposed bedtimes may have brought circadian rhythms in to line with daytime activities.	Behavioral intervention that aims to increase time in bed so as to increase sleep opportunity and, inadvertently, regularize bed/wake times. Screen access was reduced before bed, naps were prevented, and caffeine consumption reduced. In some studies, sleep education was also provided. This led to: Improved self-reported sleep quality but poorer sleep efficiency Decreased excessive daytime sleepiness Increased sleep opportunity and increased sleep duration (26–115 minutes). Sleep education did not appear to impact the outcomes	Regularizing and prescribing bed and wake times so as to increase sleep opportunity appears to be an effective intervention, with and without sleep education. Such an approach may be particularly useful where longer, more costly, more individualized approaches, are not possible or not suitable, such as in the very young or in those with cognitive impairments. Further research into the suitability of this approach for those with comorbidity, including mental health difficulty, needs to be assessed. Data from this review suggest that psychosocial distress did improve. Further study into suitability for telehealth delivery.

Note: * These recommendations and future directions were elicited from the discussion section of the papers included and from discussions of the current authors, and not necessarily substantiated in the review. Further research is required, in particular, research that isolates components of potential change.

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