Sleep Moderates Improvements in Mental Health Outcomes in Youth: Building Resilience for Healthy Kids

Abstract

Purpose

To examine the role of sleep in a school-based resiliency intervention.

Design

Single group feasibility study.

Setting

Urban middle school

Subjects

Sixth grade students.

Intervention

A total of 285, 11–12-year-old students (70% White, 18% Hispanic, 55% female) participated in the six-week 1:1 Healthy Kids intervention. Youth (n = 248) completed electronic surveys at pre–post the 6-week study assessing mental health parameters and self-reported bed and wake time.

Measures

Students were categorized as having insufficient sleep opportunity if they reported time in bed of <9 hours per night.

Analysis

General linear models examined differences between groups for each mental health parameters pre–post-study.

Results

A third of participants (28%) were classified as having insufficient sleep opportunity. Youth with insufficient sleep were more often Hispanic (27% vs 16%; P < .001) and were more often classified with both mild to severe depression and anxiety symptoms (55% vs 35%; P = .004). The health coaching intervention was found to have a significant improvement on overall resilience and self-efficacy only among students who reported sufficient sleep, while no significant intervention effect was found for those students who reported insufficient sleep.

Conclusions

Our findings suggest that youth with poor sleep health may not benefit from school-based resiliency interventions.

Keywords

health coaching mental health school wellness program social-emotional learning youth resilience sleep health

Introduction

Mental health disorders in the US continue to increase in prevalence among children and adolescents despite national efforts to intervene.¹ Poor mental health can develop early in life. One in six children aged 2 to 8 years holds a diagnosis of a mental, behavioral, or developmental disorder.² Further, rates of depression, anxiety, and suicide increase in prevalence with age. For adolescents aged 12 to 17 years, 6.1% have been diagnosed with a depressive disorder and 10.5% with an anxiety disorder.³ Resilience, defined as the protective or positive processes one utilizes to adapt when under conditions of risk (ie, life stressors),⁴ has been shown to promote positive mental health outcomes⁵ and may offer a pivotal opportunity to improve these mental health outcomes during childhood and adolescence.

Over half of US schoolchildren aged 6 to 17 years obtain insufficient sleep (<9 hours per night), with rates of insufficient sleep increasing through adolescence.^6-8 Contributors to insufficient sleep in youth include a combination of biological, environmental, and social factors. As children approach puberty, there is a physiological shift in the circadian rhythm resulting in later sleep onset, but early school start times often result in shortened sleep opportunity (ie, window of time one has to sleep).^7,9 In addition, hormonal changes, an increased sensitivity to light, reduced homeostatic sleep drive, and elevated motivation and arousal to social stimuli also contribute.⁷ High levels of artificial light at night, including from electronics use, can exacerbate these influences and further delay sleep onset time.¹⁰ Chronic sleep restriction among children and adolescents is associated with many negative impacts, including poor mood and behavior.¹¹

Existing research demonstrates a bidirectional relationship between sleep and mental health in children and adolescents, with insufficient sleep negatively impacting emotional regulation the following day and vice versa.¹² An experimental randomized crossover sleep manipulation of 50 healthy adolescents aged 14 to 17 years showed that 1 week of sleep restriction (6.5 hours sleep opportunity per night) resulted in acute increases in hostility, fatigue, anxiety, irritability, and worsened emotion regulation compared to 1 week of healthy sleep duration (10 hours sleep opportunity per night).¹³ In a cross-sectional study with adolescent participants, short sleep duration, late sleep timing, shorter duration of melatonin secretion, and an evening chronotype (ie, preference to stay up later at night) were all associated with poorer mood and behavior symptoms.¹⁴ In a clinical sample of youth ages 6 to 11 years seeking behavioral health treatment, patients were found to have insufficient sleep, and subjectively and objectively measured sleep predicted behavior and emotional symptoms.¹⁵ Insomnia is a common comorbidity with youth anxiety and depressive disorders, and sleep disturbance is associated with increased risk for suicidality.^12,16,17

Purpose

Given this known relationship, we examined the role of sleep health in a school-based health coaching intervention designed to build resiliency in sixth grade students. We have previously reported evidence for the utility of a 1:1 health coaching framework to improve youth resilience in schools to support youth mental health.¹⁸ However, it is unclear how participant sleep status impacted these findings. Thus, the goal of the current study was to examine differences in baseline mental health parameters by sleep status of participants, and to evaluate differences in the impact of the resiliency intervention for youth reporting sufficient vs insufficient sleep opportunity. We hypothesized that those with insufficient sleep opportunity at baseline would have poorer mental health indices and that the resiliency intervention would be less successful for improving mental health among youth with insufficient as opposed to sufficient sleep opportunity.

Methods

Design

Building Resilience for Healthy Kids (ie, Healthy Kids) was a single group, school-based intervention conducted in an urban middle school in Colorado Springs, Colorado from January–March 2020. The middle school demographics include 71% White students and 15% Hispanic ethnicity. A total of 16% of students were eligible for free or reduced lunch programs.

Sample

All students enrolled in sixth grade at the time of intervention were invited to participate. Both parents (via a letter) and students were given the opportunity to “opt out” of the study at any time. Interested students assented to the study electronically via RedCap by selecting 1- participate in program or 2- opt-out of program. No formal consent was required. The Colorado Multiple Institutional Review Board approved the study, and the program is registered at clinicaltrials.gov (NCT04202913).

Intervention

Healthy Kids was a six-week 1:1 universal health coaching intervention focused on improving resiliency and mental health in students. Full program details have been previously published.^18,19 In brief, each student was allocated a set time to meet with their health coach once a week for 15 minutes during the school day. During the sessions, health coaches worked with each student to recognize their own abilities and resources and assisted the students with setting goals to improve resilience in areas of the student’s choice. Areas included facilitating supportive adult-child relationships, building a sense of self-efficacy, and strengthening adaptive and/or coping skills. The health coaching sessions and goal setting activities were guided by social determination theory and goal theory. Social determination theory focuses on developing autonomy, competence, and relatedness toward a behavior to promote self-determination, internal value, and skills necessary to facilitate motivation for initiating and maintaining behaviors over time.^20,21 Goal theory was used specifically around the aspect of setting weekly and overall goals. The application of goal theory was intended to optimize youth’s goal potential by guiding youth in identifying and selecting their own goals that youth believed to be relevant, important, and feasible to attain, while also incorporating a feedback mechanism (ie, check-ins and discussions between youth and health coaches).²² In addition, discussions and goal setting activities were framed within the social-ecological model which indicates that behaviors are inherently influenced by and across multiple levels of one’s social environment (ie, intrapersonal, interpersonal, organizational, community, and public policy).²³ This allowed for the health coach to assist the youth in setting program goals that were feasible given their perceptions of their unique circumstances. Specific goal topics were chosen by students and included themes such as school performance, healthy lifestyle, and relationships. Sleep hygiene and sleep disturbance were not standard components of the Healthy Kids intervention, but students could set a sleep-related goal if desired.

Program health coaches had either a health coaching certification from an accredited program or a Master’s degree in Health Promotion that included a health coaching class within the degree curriculum, and participated in a training curriculum focused on facilitating youth resiliency through health coaching. Additional details about the health coach training protocol are provided in Lee et al (2020, 2021).^18,19

Measures

All surveys were completed by the student independently in their classroom using the electronic RedCap survey tool pre- (January 12, 2020) and post- (March 13, 2020) the intervention.

Demographics and Sleep Behaviors

Information regarding age, sex, race, and ethnicity was obtained from school records. Student’s self-reported information about their sleep at baseline including typical bed/wake times on both weekends and school days (ie, what time do you go to bed on school nights, what time do you get up on school days, what time do you go to bed on weekends, what time do you get up on weekends). Child self-report of sleep has demonstrated strong agreement compared to polysomnography.²⁴ Sleep opportunity (ie, time in bed) was calculated as the difference between bedtimes and wake times on both weekdays and weekends. Insufficient sleep opportunity was categorized as students who reported time in bed on weekdays at baseline of <9 hours per night as the recommended sleep duration for this age group is 9–12 hours/night.²⁵

Mental Health Parameters

Mood Symptoms: The PROMIS Emotional Distress Anxiety and Depressive Symptoms scales²⁶ were used to assess mood symptoms. Each 8-item short form elicits responses from the student on a 5-point scale (from “never” to “always”) over the past 7-day period. The items are summed for a score ranging from 8 to 40 with higher scores indicating more severe mood symptoms. Depression scores were then classified as <10 “normal,” 10–13 “mild,” 14–23 “moderate,” and above 24 “severe.” Anxiety scores were classified as <19 “normal,” 19-23 “mild,” 24–31 “moderate,” and above 32 “severe.” The measure demonstrated satisfactory goodness of fit and adequate internal reliability (Cronbach’s α = .85) in children and adolescents aged 8–17 years.²⁶

Academic Pressure: The Educational Stress Scale for Adolescents (ESSA)²⁷ was used to assess academic pressure. The ESSA has been validated in youth aged 12–18 years. The 16-item ESSA utilizes a Likert, 5-point scale from “1 = strongly disagree” to “5 = strongly agree.” The responses are summed for a total score, with higher scores indicating higher academic stress/pressure. The measure has demonstrated adequate internal consistency (Cronbach’s α = .81), 2-week test–retest reliability (ICC = .78), and adequate concurrent validity.²⁷

Grit: A 12-item Grit Scale validated by Duckworth et al. in youth 7–15 years old was used to assess grit.²⁸ The tool measures the non-cognitive trait of grit, defined as perseverance and passion for long-term goals. Items are rated on a 5-point Likert scale ranging from “very much like me” to “not like me at all.” Scores are summed and divided by the number of items completed, with higher scores indicating more grit. The Grit Scale has shown high internal consistency among youth (Cronbach’s α = .80).

Self-Efficacy: The Self-Efficacy Questionnaire for Children (SEQ-C) validated among adolescents aged 12–19 years was used to assess self-efficacy.²⁹ This 24-item survey assesses three domains of self-efficacy: (1) social self-efficacy, defined as perceived capability for peer relationships and assertiveness; (2) academic self-efficacy, which is the perceived capability to manage one’s own learning behavior, to master academic subjects, and to fulfill academic expectations; and (3) emotional self-efficacy, which is the perceived capability of coping with negative emotions. Each item is scored on a 5-point Likert scale ranging from “not at all” to “very well.” Subscale scores and an overall self-efficacy score are obtained by summing items, with higher scores indicating higher levels of self-efficacy. The SEQ-C demonstrated conceptually consistent factor loadings and good internal consistency (Cronbach’s α = .88).

Resilience: Social-ecological resilience was measured using the 17-item Child and Youth Resilience Measure (CYRM-R).³⁰ Students completed the CYRM-R via paper-pencil in the first session with the assistance of their health coach, but for the post-assessment the CYRM-R was completed independently in the online electronic RedCap assessment with all of the other questionnaires due to the coronavirus pandemic. However, adolescent-report questionnaires have been shown to be similar whether completed electronically or via pencil–paper.³¹ Items are rated on a 5-point Likert scale ranging from “not at all” to “a lot.” The items are summed to calculate a total score with higher scores indicating higher levels of resilience. The CYRM-R tool has been validated among youth aged 11–19 years, demonstrating good internal consistency (Cronbach’s α = .82), lack of item bias, and ability of the measure to differentiate between youth with varying levels of resilience.

Analysis

All analyses were conducted using SAS version 9.4 (SAS institute, Inc, Cary NC). Descriptive analyses compared sleep status groups using t-tests for continuous variables and chi-square tests for categorical variables. General linear models (ie, PROC GLM) were used to analyze differences between groups by each mental health parameter pre–post the intervention. Change in mental health parameter was examined similarly while controlling for baseline value of given parameter. Hedges’ g effect sizes and 95% confidence intervals (95% CI) for the effect sizes were calculated to identify the impact of the change in each of the mental health parameters by sleep status group. Hedges’ g corrects for overestimations of the true population effect present in Cohen’s d.³² Interpretations of the size of the effect are consistent with those for Cohen’s d (small = .2; medium = .5, and large = .8).³³ Alpha for the present study was set at .05.

Results

A total of 330 students were enrolled in the sixth grade class at the time of our baseline survey, of which 285 (86%) participated in the program and completed baseline measures. Demographic data (age, sex, and race/ethnicity) were collected from the students who chose not to participate. There were no statistical differences on these key demographics between those that participated vs those that did not participate. Post-intervention data were collected for 248 students (87% of initial sample); the students who did not complete the post-survey were absent on the day of data collection (n = 33) or did not have a valid time for sleep variables (n = 4). As this analysis was focused on change of mental health parameters, only data for the 248 participants with both pre–post-data were used. There were no significant differences in age, race, ethnicity, or sex of those students who completed the post-survey compared to the baseline (pre-) survey.

Almost thirty percent (28%) of students reported a time in bed on weekdays <9 hours per night (Table 1). A higher percentage of students who were reported as Hispanic ethnicity (27% vs 16%; P < .001) more often reported insufficient sleep opportunity compared to those with sufficient sleep opportunity. Students with insufficient sleep opportunity were more often classified with mild to severe depression (86% vs 63%; P = .001) and anxiety (62% vs 35%; P < .001) symptoms compared to youth with sufficient sleep opportunity. Additionally, significantly more students with insufficient sleep opportunity were classified as high risk, defined as scoring mild or higher for symptoms of both depression and anxiety (55% vs 35%; P = .004), compared to students with sufficient sleep.

Table 1.

Demographic and Baseline Mental Health Risk of Cohort Stratified by Sleep Status.

	All	Sufficient sleep (≥9 hours/Night)	Insufficient sleep (<9 hours/Night)	P-value
N	248 (100%)	179 (72%)	69 (28%)
Gender
Males	112 (45%)	84 (47%)	28 (41%)	.37
Females	136 (55%)	95 (53%)	41 (59%)
Age (years)	11.4 ± 0.5	11.4 ± 0.5	11.4 ± 0.6	.22
Race/Ethnicity
White	171 (70%)	131 (73%)	40 (58%)	<.001
Black	8 (3%)	5 (3%)	3 (4%)
Asian	11 (4%)	8 (4%)	3 (4%)
Other	13 (5%)	8(4%)	5 (7%)
Hispanic	45 (18%)	27 (16%)	18 (27%)
Depression
Normal	76 (30%)	66 (37%)	10 (14%)	.001
Mild	62 (25%)	42 (23%)	20 (29%)
Moderate	61 (25%)	44 (25%)	17 (25%)
Severe	49 (20%)	27 (15%)	22 (32%)
Anxiety	143 (58%)	117 (65%)	26 (38%)
Normal
Mild	45 (18%)	24 (13%)	21 (30%)	0.001
Moderate	4 (17%)	27 (15%)	17 (25%)
Severe	16 (6%)	11 (6%)	5 (7%)
High risk	101 (41%)	63 (35%)	38 (55%)	.004

Note: Values presented as N (%) or mean ± standard deviation. High Risk = scored Mild or higher on both PROMIS Depression and Anxiety measures.

Students who reported insufficient sleep opportunity at baseline had higher depression scores (18.8 ± 9.2 and 14.3 ± 7.9, respectively; P < .001) and anxiety symptoms scores (21.3 ± 6.8 and 17.1 ± 8.0, respectively; P < .001) and reported higher academic pressure scores (44.1 ± 14.2 and 40.3 ± 13.2, respectively; P = .05) compared to those who reported sufficient sleep (Table 2). Further, students with insufficient sleep opportunity at baseline reported lower total self-efficacy scores (75.8 ± 13.2 and 82.3 ± 15.3, respectively; P = .005), emotional self-efficacy (23.1 ± 5.1 and 25.8 ± 6.0, respectively; P = .002), academic self-efficacy (25.9 ± 5.8 and 28.5 ± 5.9, respectively; P = .002), and grit scores (2.7 ± 0.5 and 2.9 ± .5, respectively; P = .02) at baseline. Similarly, at post-test, students with insufficient sleep opportunity continued to endorse higher depression scores (18.0 ± 9.0 and 13.9 ± 7.4, respectively, P < .001) and anxiety scores (20.6 ± 7.5 and 16.9 ± 7.8, respectively; P < .001). At post-test, those with insufficient sleep opportunity reported lower emotional (25.8 ± 6.9 and 28.6 ± 6.8, respectively; P < .01) and academic (28.6 ± 6.9 and 31.4 ± 6.1, respectively; P < .01) self-efficacy and continued to report higher academic pressures (44.8 ± 14.9 and 40.5 ± 12.9, respectively; P = .02). No significant differences in change of each parameter by sleep status were present upon controlling for baseline level of the respective outcome (Table 2).

Table 2.

Pre–Post Mental Health Parameter Scores Stratified by Sleep Status.

	All n = 248	Sufficient sleep	Insufficient sleep (<9 hours/Night)	P-value
Baseline
Resilience
Total	75.6 ± 6.9	75.6 ± 6.6	75.8 ± 7.7	.87
Personal	43.7 ± 4.5	43.2 ± 4.4	45.1 ± 4.2	.002
Relationships	32.0 ± 3.1	32.0 ± 3.1	32.1 ± 3.1	.85
Grit	2.9 ± 0.5	2.9 ± 0.5</b>	2.7 ± 0.5	.02
Self-efficacy
Total	80.6 ± 15.0	82.3 ± 15.3	75.8 ± 13.2	.005
Social	27.7 ± 5.9	28.1 ± 5.8	26.6 ± 5.9	.09
Emotional	25.1 ± 5.9	25.8 ± 6.0	23.1 ± 5.1	.002
Academic	27.8 ± 6.0	28.5 ± 5.9	25.9 ± 5.8	.002
Academic pressure	41.4 ± 13.6	40.3 ± 13.2	44.1 ± 14.2	.05
Mood symptoms
Depression	15.5 ± 8.5	14.3 ± 7.9	18.8 ± 9.2	<.001
Anxiety	18.3 ± 7.9	17.1 ± 8.0	21.3 ± 6.8	<.001
Follow-up
Resilience
Total	77.8 ± 6.6	78.1 ± 6.6	77.0 ± 6.6	.26
Personal	45.0 ± 4.4	45.2 ± 4.3	44.4 ± 4.7	.20
Relationships	32.8 ± 2.9	32.8 ± 3.0	32.6 ± 2.7	.56
Grit	2.9 ± 0.5	2.9 ± 0.5	2.8 ± 0.4	.05
Self-efficacy
Total	90.5 ± 18.2	92.2 ± 17.4	85.6 ± 19.7	.03
Social	30.2 ± 6.4	30.4 ± 6.2	29.6 ± 6.9	.36
Emotional	27.8 ± 6.9	28.6 ± 6.8	25.8 ± 6.9	<.01
Academic	30.7 ± 6.4	31.4 ± 6.1	28.6 ± 6.9	<.01
Academic pressure	41.7 ± 13.6	40.5 ± 12.9	44.8 ± 14.9	.02
Mood symptoms
Depression	15.1 ± 8.1	13.9 ± 7.4	18.0 ± 9.0	<.001
Anxiety	17.9 ± 7.9	16.9 ± 7.8	20.6 ± 7.5	<.001
Change pre–post intervention (controlling for baseline score)
Resilience
Total	2.1 ± 9.3	2.5 ± 9.1	1.3 ± 9.7	.26
Personal	1.3 ± 5.8	2.1 ± 5.6	−.6 ± 5.9	.08
Relationships	.8 ± 3.8	.8 ± 3.8	.5 ± 3.7	.52
Grit	.1 ± 0.4	.04 ± 0.4	.1 ± 0.3	.92
Self-efficacy
Total	9.1 ± 12.8	9.0 ± 12.3	9.2 ± 14.6	.48
Social	2.5 ± 4.7	2.3 ± 4.6	2.9 ± 4.8	.93
Emotional	2.8 ± 5.2	2.9 ± 5.1	2.5 ± 5.3	.19
Academic	2.3 ± 4.6	2.4 ± 4.4	2.2 ± 5.4	.22
Academic pressure	.2 ± 10.0	.1 ± 10.9	.7 ± 7.4	.15
Mood symptoms
Depression	−.5 ± 6.1	−.4 ± 6.4	−.7 ± 5.1	.15
Anxiety	−.3 ± 6.6	−.2 ± 6.9	−.7 ± 5.9	.22

Effect size values and 95% CI’s for change in each mental health parameter pre–post-intervention by sleep status are shown in Figure 1 pre–post-intervention change stratified by sleep status. Among students reporting sufficient sleep opportunity, the intervention was found to have a significant improvement on overall resilience and personal-related resilience, as well as on all measures of self-efficacy (P < .05). However, there was no significant intervention effect on any mental health parameter for the students who reported insufficient sleep opportunity.

Figure 1.

Pre–post-intervention change stratified by sleep status.

Discussion

One-third of a school-based sample of sixth graders reported insufficient sleep opportunity of <9 hours time in bed per night. These participants were more likely to be non-white and Hispanic and more likely to endorse elevated depression and anxiety symptoms. The school-based health coaching intervention was associated with significantly improved personal- and relationship-related resilience, overall resilience, and social and emotional self-efficacy for youth with sufficient sleep opportunity. However, the intervention did not have a significant effect for those participants with insufficient sleep opportunity. These findings indicate that specifically addressing sleep health may be an important consideration for future school-based mental health interventions.

Similar to our findings, other studies have found poor sleep health in middle school-age youth. One survey of over 1000 middle school students reported high rates of trouble sleeping, daytime sleepiness, and fighting with parents about bedtime.³⁴ The prevalence of short sleep duration (defined as <9 hours for youth 6–12 years and <8 hours for youth 13–18 years) in middle school participants in the Youth Risk Behavior Surveys was nearly 60%.³⁵ Insufficient sleep places youth at risk for physical and mental health problems, including obesity, diabetes, behavior problems, and poor academic performance.³⁴ School-based sleep interventions for youth have been previously trialed, but unfortunately have been minimally effective in improving sleep health. Notably, there are few existing interventions that increase sleep duration by 30 minutes or more per night (Kaar et al 2020). Yet, school-based interventions have the advantage of reaching a large number of children in an environment where they are used to learning. To our knowledge, no research has examined the impact of adding a sleep-specific treatment component to a mental health intervention to maximize treatment effect. Given our findings that our school-based health coach resiliency intervention was effective only for youth obtaining sufficient sleep, novel approaches to improve sleep health in the context of mental health interventions are urgently needed.

Hosker et al. suggest that augmenting mental health interventions with sleep improvement strategies may allow treatments to be more effective and comprehensive.³⁶ These authors recommend the PERMA model of well-being to highlight the role of sleep in improving mental health.³⁷ Linking sleep to each of the PERMA constructs, including Positive emotions, Engagement, Relationships, Meaning, and Accomplishments may help youth and families meet recommendations.^36,37 For example, associating sleep with positive emotion could entail asking youth to reflect on how they feel after waking up after a good night’s sleep, while linking sleep to relationships may involve asking youth to think about how they say goodnight to family members before bed.³⁶ Further research is needed on the feasibility, acceptability, and effectiveness of incorporating sleep into mental health interventions for youth in school settings.

The current findings should be taken in the context of the limitations of the study, including a single group design without a control group comparison, and a reliance on retrospective and subjective account of sleep rather than real-time sleep dairies or objective sleep monitoring. Given the pilot nature of the current study, we were not able to obtain information from each student about specific modifiable and non-modifiable factors that may be related to sleep, such as sleeping space in the home or work or family responsibilities that may interfere with sleep. For privacy reasons, we were also not able to assess previous medical or mental health diagnoses or family characteristics (eg, socioeconomic status). We recommend these factors are assessed and considered in future research. Moreover, we experienced a disruption in collecting post-data due to the coronavirus (COVID-19) pandemic, as 33 students were absent to school on the post-test collection day of our survey likely due to impending school closures related to the COVID-19 pandemic. Finally, we do not have follow-up data to assess if changes occurred later (ie, not immediately post-intervention) as students may have needed more time to put in place the guidance provided by the health coaches. However, strengths of our study include an overall high participation rate, relatively large sample size, the ability to conduct a 1:1 intervention within the school setting, and robust evaluations using validated assessment tools.

Conclusions

Mental health problems tend to emerge during childhood and adolescence, and symptoms may persist if untreated.^1,38 Intervening to improve mental health in the school setting is a feasible approach that allows for wide reach and an efficient means of disseminating treatment with a potential for broad public health impact. However, our findings suggest that youth with poor sleep health may not benefit from these interventions. Thus, future research incorporating a specific sleep health intervention component into our school-based health coaching intervention would be valuable to see if improving sleep helps short sleepers experience the same benefits of the intervention as those obtaining sufficient sleep.

SO What?

What Is Already Known on This Topic?

Youth with poor sleep behaviors have been reported to have poor mood, including increased symptoms of depression and other mental health parameters, compared to youth who are reported having healthy sleep behaviors.

What Does This Article Add?

Strategies that are effective for improving mental health in youth may not be equally effective for all youth, in particular those youth that have poor sleep behaviors.

What are the implications for health promotion practice or research?

Strategies to improve youth mental health need to consider how sleep behaviors may influence intervention outcomes. Youth with poor sleep behaviors may need an intervention that includes sleep health education incorporated into the development of the core program.

Footnotes

Acknowledgments

The authors would like to thank the students, teachers, administrators, counselor, and principals who participated in this study for warmly welcoming us into their school and support and contributions to scheduling health coaching sessions. We would also like to thank the project steering committee for their dedication and commitment to helping optimize the study protocol and support and benefit to the participating youth. Additionally, we would like to thank the health coaches for their dedicated service in this study. Finally, the authors would like to thank the health coach instructors for their development of a robust training curriculum to best prepare the health coaches for their participation in the study and interaction with youth.

Authors Contributions

Simon SL and Kaar JL conceived and designed the analysis. Simon SL wrote the first draft. Bowen BS, Lee JA, and Heberlein E collected the data and interpreted the data analysis. Ware MA, Chandrasekhar JL, Shomaker LB, and Gulley LD critically revised the article. All authors gave final approval of the version submitted.

Clinical Trials Registration

This article has been registered with Clinical Trials. Colorado Springs School-Based Resiliency Project registration number: NCT04202913. Date of registration: 12/16/2019.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Colorado Springs Health Foundation.

IRB Protocol

Funding source for the trial: Children’s Hospital Colorado Springs and community donors, Institutional review board: Colorado Multiple Institutional Review Board, Approved 11/13/2019

ORCID iDs

Jessica L. Chandrasekhar

Jill L. Kaar

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