Triple Vulnerability? Circadian Tendency, Sleep Deprivation and Adolescence

Teens who exhibit a circadian tendency toward eveningness ('night-owls') follow a delayed
sleep schedule, increasing activity later in the day and both going to sleep and getting up
later, compared to morning-types ('larks'). The circadian tendency toward eveningness during
adolescence arises from a confluence of psychosocial, behavioral and biological factors and
is an important contributor to, and maybe even cause of, vicious cycles that escalate
vulnerability and risk for poor health and major forms of psychopathology. Indeed, an evening
circadian tendency has been associated with a wide range of adverse effects including poorer
health, poorer academic performance, poorer self-regulation, greater use of substances,
greater tendency for impulsivity, more depression and anxiety, greater emotional instability
and more aggressive and antisocial behavior. While the biological shift toward eveningness
during puberty may be difficult to modify, the psychosocial and behavioral contributors are
modifiable. Moreover, modifying these contributors will eliminate key factors that exacerbate
the biological shift. The proposed research will advance current knowledge on the role of
eveningness as a mechanism contributing to poorer outcomes during adolescence. The
investigators aim to reduce eveningness among 10-18 year olds via an intervention which
integrates evidence-based treatments derived from basic research on the circadian system
(Treatment 1) compared to a psychoeducational intervention that highlights the interplay
between sleep, diet, exercise and stress (Treatment 2). The investigators will randomly
allocate adolescents with an evening circadian tendency, and who are 'at risk' in at least
one of five health domains (emotional, cognitive, behavioral, social, physical), to either:
(a) Treatment 1 (n = 86) or (b) Treatment 2 (n = 86). Measures will be taken pre-treatment,
post-treatment, and at 6 and 12 months post-treatment. This research is a first step within a
longer term plan to accelerate knowledge on the potentially powerful positive effects, for
the developing neural system, of simple, disseminable psychosocial interventions specifically
designed to target modifiable risk factors across adolescence.

Inclusion criteria.

1. Scoring within the lowest quartile of the Children's Morningness-Eveningness
Preferences Scale (CMEP; 27 or lower) and a 7-day sleep diary showing a sleep onset
time of of 10:40 pm or later for 10-13 year olds, 11 pm or later for 14-16 year olds,
and 11:20 pm or later for 17-18 year olds at least 3 nights per week. Must have had
the current pattern of late bedtimes for the last 3 months.

2. 'At risk' in one of the five health domains: emotional, behavioral, social, physical,
and cognitive. Emotional risk will be operationalized as a score of 4 or above on any
of the following items on the Child Depression Rating Scale: Difficulty Having Fun,
Social Withdrawal, Irritability, Depressed Feelings, Excessive Weeping, or a T-score
of 61 or above on the Multidimensional Anxiety Scale for Children (MASQ), based on age
group (10-11 years, 12-15 year, 16-19 years) using the MASC-10 Profile. Behavioral
risk will be operationalized as a Sensation Seeking Scale score greater than 3.93 for
males ages 10-13, greater than 3.19 for females 10-13, greater than 4.07 for males
14-18, or greater than 3.19 for females 14-18; taking ADHD medication or Kiddie
Schedule for Affective Disorders and Schizophrenia for School-Age Children (KSADs)
diagnosis of ADHD; current alcohol or substance abuse; or past alcohol or substance
dependence. Social and cognitive risk will be defined as "worse" than others the
teen's age in one or more social behavior from Child Behavior Checklist (CBCL) Section
VI or failing one or more academic class from CBCL Section VII, respectively. Physical
risk will be operationalized as a Physical Health Questionnaire-15 score of 4 or
above, six or more days of school absences, or a BMI above the 85th percentile for the
participant's sex and age.

3. Age between 10 and 18 and living with a parent or guardian and and attending a
class/job by 9am at least 3 days per week;

4. English language fluency;

5. Able and willing to give informed assent.

Exclusion criteria.

1. An active, progressive physical illness (e.g., cancer, respiratory disorder) or
neurological degenerative disease directly related to the onset and course of the
sleep disturbance;

2. Evidence from clinical diagnosis or report by youth or parent of sleep apnea, restless
legs or periodic limb movements during sleep. Youth presenting with provisional
diagnoses of any of these disorders (e.g., sleep apnea) will be referred for a
non-study polysomnography (PSG) evaluation at the parent's discretion and will be
enrolled only if the diagnosis is disconfirmed;

3. Mental retardation, autism spectrum disorder, or other significantly impairing
pervasive developmental disorder. Based on previous recruitment experiences in our
youth depression study, we expect this exclusion to be invoked very infrequently (once
every few years);

4. Bipolar disorder or schizophrenia or another current Axis I disorder if there is a
significant risk of harm and/or decompensation if treatment of that comorbid condition
is delayed as a function of participating in any stage of this study. Otherwise, we
will allow all other comorbid psychiatric conditions to (i) to maximize
representativeness and (ii) because a byproduct may be that the treatment constitutes
a helpful 'transdiagnostic' treatment for youth across psychiatric disorders.

5. A medication-free group may be difficult to recruit and would likely be
unrepresentative. Hence, participants will not be excluded on the basis of stable use
of medications (> 4 weeks). The exception was use of hypnotics and other medications
known to alter sleep (e.g., melatonin).

6. History of substance dependence in the past six months;

7. Current suicide risk sufficient to preclude treatment on an outpatient basis.