Promoting Teenage Sleep - for Better Mental Health and School Performance
Phase: NA
Conditions: Mental Health Issue, Insomnia, Depression, Anxiety, Daytime Sleepiness, Wellness, Psychological
Sponsor: Kristianstad University

 
 
 
2024 
Promoting teenage sleep for improved mental health 
and school performance: Research plan 
FEBRUARY 23, 2024 
PERNILLA GARMY, ANNIKA NORELL, CHRISTINA SANDLUND, SERENA 
BAUDUCCO 

1 
 
Promoting teenage sleep for improved mental health and school 
performance: Research plan 
Introduction 
Sleep problems are common among young people and there are connections between sleep problems 
and mental health, concentration problems, and lower grades (Hedin et al., 2020, Sampasa-Kanyinga 
et al. 2020). Over time (historically since the 80’s), teenagers sleep less and less and too little, which 
affects mental health and school performance in the short term. Long-term lack of sleep increases the 
risk of leaving school with failed grades and of having long-term health problems. It is therefore 
important to break this trend. 
A challenge in existing preventive sleep programs is to motivate young people to change their sleep 
habits. Just like adults, teenagers have many activities that demand their time. It can therefore be 
difficult to balance sleep with schoolwork, exercise, etc. Young people need knowledge about sleep 
to gain an understanding of how it can affect their mood and ability to cope with school. The reasons 
for the lack of sleep among young people are multifold: the 24-hour society and easily accessible 
entertainment/society via technology use, puberty-related changes in the circadian rhythm, and stress 
about the future (Becker et al., 2015). The school has a clear responsibility for the students' knowledge 
and understanding of the importance of lifestyle for health as well as for supporting the students in 
orienting themselves in society. The school is therefore a natural arena to reach out to teenagers 
because most young people are there, and the school health department can offer health-promotion 
initiatives. 
The overall aim of this project is to evaluate the effectiveness of two school-based programs that have 
the potential to promote adolescent sleep and prevent future depressive symptoms. The programs 
will be offered to students aged 13-19 at Swedish high schools and upper secondary schools at the 
classroom level. The students will be compared to teaching as usual (control group). 
Sleep on schedule is a program (5 lessons over 5 weeks) that integrates sleep knowledge and skill 
training to promote good sleep routines. Technology restriction (TechRest) is a program (2 lessons over 
2 weeks) that targets mobile phone use at bedtime. Both programs have shown good results (up to 
20 minutes more sleep on school days). The current goal was to test the effects of the programs on 
young people in a Swedish context to investigate if they can affect teenagers' sleep and mental health. 
The study design is a cluster-randomized study where schools are randomized to either 1) Sleep on 
schedule, 2) Technology restriction, or 3) Control group (no intervention). All schools will be informed 
of the results and receive training in the program that proves to be most effective at the end of the 
project, if desired. The intervention is aimed at students aged 13-19. The study want to involve large 
parts of the school's staff and avoid that knowledge and responsibility resting on a few members of 
staff. The program will be delivered by teachers or school health professionals (e.g., school counsellor, 
school nurse). 
The interventions will directly benefit young people because sleep problems are a risk factor for 
mental illness and worse school performance. Sleep on schedule and restricting use of technology are 
important life skills and strategies that can help young people manage their everyday lives both now 
and in the future. The study offers benefits to the students in the intervention group in that they can 
learn strategies for preventive purposes regarding sleep before clinical problems arise. The 
participants will also have their voices heard on the subject. 

2 
 
Area overview 
Sleep is important for both physical and mental health as well as for learning. During adolescence, 
sleep is affected by both biological and psychosocial changes. In teenagers, sleepiness accumulates 
more slowly than in younger children, which means that they are more alert in the evenings and want 
to go to bed later (Crowley et al. 2018). In addition, teenagers often spend more time with peers 
(compared to when they were younger) as well as having higher workloads in school and in leisure 
activities. All these obligations must fit into the waking hours of the day (Becker et al. 2015). This 
collectively causes teenagers to frequently go to bed later to make time, but sleep time is reduced 
because school often starts early. Approximately 20-30% of Swedish adolescents between 13 and 15 
years of age report that they have problems with sleep, which include difficulty falling asleep, short 
sleep time, delayed sleep phase, and daytime fatigue (Norell-Clarke & Hagquist 2017). The problems 
increase as teenagers get older (Inchley et al., 2020). In addition, there has been a trend in Sweden 
where more teenagers go to bed late on school days and sleep less than recommended; this has been 
observed since the late 1980s (Norell-Clarke & Hagquist, 2017). 
 
It is worrying that teenage sleep duration and sleep quality are decreasing, especially given the clear 
link between sleep and mental health, especially depression (Palmer & Alfano, 2017). Depression is 
rare in children before puberty, but increases from age 14 (American Psychiatric Association, 2013). 
Depression is one of the most common causes of disability among teenagers (World Health 
Organization, 2021). Research shows that poor sleep may actually be a risk factor for the development 
of depressive symptoms rather than the other way around (Lovato & Gradisar, 2014; Scott et al., 
2021). This underscores the need for preventive measures to improve sleep health in early 
adolescence. 
Being mentally or physically alert or tense instead of relaxed at bedtime is incompatible with falling 
asleep. Difficulties falling asleep at bedtime can be caused by worry or disturbing thoughts or by 
engaging in activities that require attention and quick reaction just before bedtime (for example, 
playing computer games) or an environment incompatible with sleep (for example, a bright room in 
the evening). In a comprehensive meta-analysis, good sleep hygiene, defined as both daily routines 
and an environment that promotes good sleep (Irish et al., 2015), was identified as one of the most 
powerful protective factors for adolescent sleep. A stressful home environment, on the other hand, 
was consistently associated with a lack of sleep, while parents having rules for children's bedtimes 
was beneficial for good sleep among children and adolescents (Bartel et al., 2015). 
School-related stress (performance demands, strained relationships with teachers and peers, and 
perceived high workload) is one of the most common daily stressors in early adolescence (Hörbo et 
al., 2021). Teenagers may also delay their bedtime due to schoolwork and/or worries about school, 
thus affecting both sleep duration and sleep quality. When teenagers are interviewed, school-related 
stress and technology use are among the top causes of poor sleep (Hedin et al., 2020, Gruber et al., 
2017, Penayo, 2015). Fortunately, it is possible to teach teenagers healthy sleep habits and strategies 
to manage both stress and technology use. Involving support from peers is also important at a time 
when peers are becoming more influential (Hörbo et al., 2021). The school environment is a natural 
arena for promoting healthy habits (Garmy, 2016) and offers opportunities to reach both families and 
the peer environment. 
There is a need to test the effectiveness of school-based interventions to promote healthy adolescent 
sleep habits and evaluate their long-term benefits. School-based interventions to prevent physical and 
mental ill-health have been shown to be cost-effective because most teenagers are in school (Durlak, 
2011), and promoting health is a main objective of school health care services (Garmy, 2016). 

3 
 
The associations between lack of sleep and adolescent daily functioning—including physical and 
mental health and school performance (Shochat et al., 2014)—have led to a series of intervention 
studies aimed at improving adolescent sleep. In general, school-based universal interventions have 
been moderately successful because teenagers learn about sleep through sleep education, but that 
knowledge does not translate into changes in their sleep habits (Cassoff et al. 2013, Blunden, 2017, 
Blunden & Rigney, 2015). Qualitative studies have shown that teenagers are often aware of the 
importance of sleep and that many wish to sleep more or better. Based on previous research, it seems 
important to target stress and technology use (Hedin, et al., 2020, Gruber et al., 2017, Penayo, 2015). 
In line with this, the few studies that target these barriers have been successful in producing a 
behavioral change (e.g., longer sleep duration). For example, Bonnar et al. (2015) used motivational 
interviewing (MI) that created 30 minutes longer sleep duration with reduced depressive symptoms 
in the participating teenagers. Bartel et al. (2019) aimed to reduce the time with mobile phones in bed 
and reported 20 minutes more sleep. Further, Bauducco et al. (2020) taught better time planning 
resulting in long-term effects on sleep duration. These programs have shown promising results and 
contain effective components that should be tested further (see Table 1). 
 
Theoretical model 
Motivational interviewing (MI) (Miller & Rollnick, 2012) is a useful framework when working with 
young people because it is non-confrontational and respectful of the person's autonomy, which are 
sensitive areas during this developmental period (Cassoff et al., 2013). MI is based on four important 
principles including showing empathy for the person, raising ambivalence between current behavior 
and the person's goals and values, adapting to resistance (i.e., non-confrontational attitude to 
resistance), and supporting autonomy. Thus, MI aims to resolve the ambivalence created by, for 
example, the advantages and disadvantages of earlier bedtime (Cain et al., 2011). In other words, 
individuals need to feel "ready" (i.e., the time must be right for change and commitment), "capable" 
(i.e., they must feel confident) and "willing" (i.e., they must appreciate that the change is important) 
to be able to change their behavior.  
Another characteristic of MI is that it is person-centered, meaning that it is adaptable to individual 
needs (Cassoff et al., 2013). MI has been integrated into sleep education in the past and has been 
successful in improving youth motivation (Bonnar et al., 2015; Cain et al., 2011). From an MI 
perspective, readiness, ability, and willingness should be promoted in the beginning of an intervention 
and this naturally makes the intervention longer. This corresponds with universal interventions where 
only a few might identify a need for change. Interventions on selective or indicated levels might 
assume that individuals at risk or with symptoms might already be ready for change and therefore a 
shorter targeted intervention might be justified. The latter is supported by a qualitative study that 
shows that young people know that sleep is important and wish to get more sleep (Jakobsson et al., 
2022). 
 
Scientific question 
The purpose of the project is to evaluate the short-term and long-term effectiveness of the two 
programs on both the students' sleep and mental health as well as to evaluate the implementation in 
the school. 
• 
Does sleep on the schedule taught in the classroom on five occasions affect sleep duration, 
perceived sleep quality, and mental health? Will the effects remain 1 year after the end of the 
program? 

4 
 
• 
Does Technology restriction before bedtime affect sleep duration, perceived sleep quality, 
and mental health? Will the effects remain 1 year after the end of the program? 
The project will evaluate the programs using the RE-AIM framework. Limitations found with previous 
studies include short-term evaluations, a limited number of outcomes (effect on sleep but not on 
mental health), or a technology restriction with only two evaluations among older youth, although 
those show that technology restriction was associated with promising effects (Bartel, Shereen & 
Gradisar, 2019). 
The questions answered with quantitative data are as follows: 
• 
Does Sleep on the Schedule affect students' sleep duration, sleep habits, daytime symptoms, 
perceived sleep quality, grades, and physical/mental health versus a control group? 
• 
Does Technology restriction affect students' sleep duration, sleep habits, daytime symptoms, 
perceived sleep quality, mobile use, grades, and physical/mental health versus a control 
group? 
• 
To what extent have the respective programs been disseminated in the schools, reached the 
students, and been implemented as intended? 
• 
What is the health economic aspects of Sleep on Schedule and Technology restriction? 
 
The questions answered with qualitative data are as follows: 
• 
What are the school staff's experiences of taking part in the training on the Sleep on Schedule 
and Technology restriction interventions? 
• 
What are school staff's experiences of delivering the Sleep on Schedule and Technology 
restriction interventions? 
• 
What are the students' experiences of participating in Sleep on Schedule? 
• 
What are the students' experiences of participating in Technology restriction. 
• 
What are the guardians' experiences of the young people using mobile phones before bedtime 
before and after participation in the Technology restriction. 
• 
What are guardians' experiences of their young people's sleep habits and mental health 
before and after Sleep on Schedule. 
 
Methods 
 
Study design: Cluster-randomized trial. 
Schools will be randomized to either 1) Sleep on Schedule, 2) Technology restriction, or 3) Control 
group (no intervention). All schools will be informed of the results and receive training in the program 
that proves most effective at the end of the project, if so desired. 
The intervention is aimed at students in grades 7 and 8 in high school and grades 1 and 2 at upper 
secondary school. The project want to involve large parts of the school's staff, so that the responsibility 
does not lie with individual members of the staff. The program will be delivered in collaboration 
between teachers and school health care professionals (e.g., school counsellor, school nurse). 
Teachers who have previously participated in Sleep on Schedule have taught subjects related to sports 
and health, biology, and social studies.  

5 
 
The principal, the school health care professionals, and interested teachers will receive practical 
training in the interventions to be tested (this does not apply to the control group who will receive it 
at the end of the project) and all staff and parents (via the school's communication system) will receive 
information. The training will be given digitally and is divided into two meetings, two hours each. The 
first session involves background of the project, adolescent sleep, how the program works, and 
reviewing the program manual. Session 2 contains data collection instructions and questions (incl. 
control schools). The research team will be available and supervise the school staff during the 
programs’ implementation and data collection. 
Table 1: Description of the two interventions and one control group. 
 
Sleep on the Schedule
 
 
TechRest 
Control 
Length 
1 lesson per week for 5 
weeks  
2 lessons with 2-week 
interval  
School as usual  
Conducted by 
School staff (teachers, school 
health care professionals) 
School staff (teachers, 
school health care 
professionals) 
School staff (teachers, 
school 
health 
care 
professionals) 
Integrated in the 
school 
curriculum 
Yes. Homework and 
attendance  
Yes. Homework and 
attendance 
School as usual 
Components 
Sleep education + practical 
skills training (time 
management, healthy sleep 
habits, problem solving) + 
involvement of parents and 
peers 
Limiting screen use in 
the evening one hour 
before bedtime  
  
School as usual 
Theory/ 
rationale 
Motivating interviewing 
(MI): 
 
The lessons were developed 
based on Cain et al. (2011) 
but were adapted to fit into 
the motivational 
interviewing (MI) framework 
which promotes readiness, 
willingness, and ability by 
providing knowledge and 
tools for change.  
 
Cognitive 
and 
behavioral 
therapeutic 
principles 
underlie the content of the 
techniques that are being 
taught. 
The motivational 
interviewing (MI) 
framework:  
Promoting ability by 
removing barriers. 
 
The perfect storm 
model, which includes 
screen use in its latter 
adaptation.  
 
Previous results 
The length of sleep increases 
by about 20 minutes, and 
leads to improvements in 
depressive symptoms. 
The length of sleep 
increases by about 20 
minutes. 
 
 

6 
 
Time schedule 
The plan is to train school staff and start the program in April 2024. Data  will be collected 2024 - 2027. 
At the end of the project (after the last data collection), schools will receive training in the sleep 
program that demonstrates the best results, if desired. There will also be an offer to give a lecture on 
sleep and to report back the results from the study.  
Data collection 
Students will complete digital questionnaires during regular lessons at school. Data collection takes 
place for all schools (regardless of intervention) before the start of the program (baseline), at the end 
of the program, and one year after completion. Data is de-identified and sent to the researchers in a 
secure manner. One week before the Technology restriction intervention, students will be asked to 
fill in a sleep form and indicate when they usually stop using their screens for the night to adapt the 
Technology restriction time to each individual student. Students will also complete an accompanying 
form (background questions, sleep knowledge, sleep hygiene, sleep habits, insomnia symptoms, 
physical and mental health, and motivation). A sample (about 80) of the students from both 
intervention and control groups will be asked to wear an actigraph to validate self-estimation of sleep. 
The baseline period will be approximately the same regardless of intervention and will be at the 
beginning of the semester. Post-test after the end of the interventions. The schools/classes will be 
matched to interventions again one year after the end of the intervention. 
Interim analysis (Kumar & Chakraborty, 2016) will be applied meaning that an analysis of the primary 
outcome measures will be performed when 50% of the planned data have been collected. If the result 
is significant, then the remaining data collection will be interrupted. This can save time and resources, 
but also not expose the study participants to "unnecessary" data collection. Adjustments for normal 
routines may need to be made in the case of repeated significance tests on data that are being 
collected. 
 
Material  
All materials for teaching (e.g., PowerPoint slides, manuals, sleep diaries) and for data collection (the 
questionnaires) are ready to use and have been developed in collaboration with other schools to adapt 
to the school's digital communication platform. 
The questionnaires that will be used have been used in several previous studies, and no problems 
have been reported due to the nature of the questions. School healthcare service is informed that the 
study is ongoing, and students are encouraged to seek help from school healthcare service if needed. 
Students will be requested to answer the following questionnaires in order to answer the research 
questions about sleep duration, sleep habits, daytime symptoms, perceived sleep quality, mobile 
phone use, grades, physical and mental health, and motivation. 
• 
Background data (age, sex, country of birth, socioeconomic status, academic success) 
• 
Adolescent Sleep Hygiene Scale (ASHS) - Sleep 
• 
(Modified) School Sleep Habits Survey (SSHS) - Sleep and mobile phone use in the evening 
• 
Insomnia Severity Index (ISI) - Sleep 
• 
EQ VAS  – Physical and mental health 
• 
CHU9D - Measuring health and calculating QALYs for children and adolescents 
• 
Hospital Anxiety and Depression Scale (HADS) – Mental health 
• 
Sleep knowledge – Sleep 
• 
Metacognitions Questionnaire – Adolescents (MCQ-A)- Metacognitions 

7 
 
• 
Academic Self-Regulation Questionnaire (SRQ-A) – Intrinsic motivation subscale Why I do 
things - Motivation 
 
Process evaluation will test motivation (3 MI questions in the survey), attendance, program fidelity, 
and homework completion. The students' experiences of participating in a school-based sleep 
intervention, student health staff's experiences of providing the sleep intervention, and teachers' 
views on student participation and integration of sleep education will be evaluated. 
 
Sleep on Schedule 
The sleep training includes five lessons during school hours, and will be held by school staff (teachers, 
school nurses and school counsellors). The teaching consists of sleep education (sleep knowledge and 
good sleep routines), time management (e.g., planning homework without distraction, planning other 
activities, quiet time before bedtime), information to guardians, and discussions with peers in the 
classroom (e.g., rules regarding evening interaction via electronic media). Homework/exercises and 
behavioral experiments are also included. Data collection takes place in connection with the first and 
last lesson of Sleep on Schedule. 
 
TechRest 
This intervention has been tested in Australia with a small sample of teenagers, and it was associated 
with promising effects (Bartel, Shereen & Gradisar, 2019). The data collection consists of a digital 
questionnaire regarding sleep habits, insomnia, motivation, physical and mental health, and electronic 
media use; a selection of students will use the actigraph for a week. After the first week, the 
participants will be instructed to stop using screens 1 hour before their usual bedtime. After one week 
has passed, participants in the Technology restriction intervention will be asked to complete the 
previously mentioned questionnaires as well as questions about the intervention itself: its 
applicability, compliance, and whether or not they will continue to limit their screen time before 
bedtime. One year after the intervention, they will be asked to complete the same questionnaire as 
at baseline. A selection of students will also wear a wrist actigraph. 
 
All classes in schools that agreed to participate will be randomized to intervention or control, i.e., so-
called cluster randomization. Conclusions about differences and effects are drawn at the cluster level 
and not at the individual level. All students are asked to participate in the study. Written informed 
consent will be obtained from students under and over the age of 15 and from all guardians of 
students under the age of 15. 
 
Power calculation 
Sample size calculations were used to estimate the number of clusters in a three-arm randomized 
cluster trial with a continuous outcome at 80% power and an alpha of 0.05. 
In this calculation, the following assumptions are made: 
• 
Power 80% 
• 
Alpha 0.05 
• 
3 arms 

8 
 
• 
60 students in each cluster (ca. 2 classes) 
• 
Variance within cluster: 30 min => SD 42 min 
• 
Variance between cluster:  15 min => SD 30 min 
Mean values:  
• 
Control: 8 hours 
• 
Sleep on Schedule: 8 hours and 6 minutes 
• 
TechRest: 8 hours and 21 minutes  
85 clusters are needed meaning a total number of students 85*60 = 5100 students. However, the plan 
is to initially do a feasibility test of the interventions with a lower number of participants to investigate 
the feasibility. 
For interview studies with students, leaders and guardians, approx. 30 participants are calculated per 
study. This is will help reach a variety of experiences. 
 
Management of research data 
Survey responses are answered digitally via Kristianstad University's web tool Evasys. Collected data 
will be stored securely so that no unauthorized person can access it and in accordance with the GDPR 
legislations. The informants will be named with a code written on a code list; each person will get a 
number. The code list is kept separately from information about the informants in a safe, and only 
those responsible for the present study will have access to the code list. During the course of the 
study, consent forms, code list, audio files, and transcribed interviews will be kept locked in a safe. 
Research data must be handed over to HKR’s archives when the project is finished, i.e., when the 
results of the research project have been reported and published or otherwise made public.  
 
Ethical considerations 
The research will be carried out in school environments. Most of the activities performed within the 
school is compulsory. Participating in Sleep on Schedule and Technology restriction takes place during 
school hours, but the research steps (filling in questionnaires and participating in interviews) are 
voluntary. There is a risk that students do not perceive that they have the option to refrain from 
participating in the research. This risk is taken into account by thoroughly informing school staff who 
will ask students to participate. It is particularly important to make it clear to students and guardians 
that participation in research is voluntary and that it does not affect the students' other assessments 
of school performance. 
Answering questionnaires and interview guides about mental and physical health could be 
experienced as unpleasant. However, all questionnaires and interview questions have been used 
without reported problems in previous studies, and no negative experiences have emerged. However, 
the school health care services are prepared to handle problems if the need arises. 
Regarding the young people's participation in the evaluation, consent will be collected after they have 
been informed in writing and orally about what participation entails. It will be clear that their 
participation in the study does not affect the grade for the course and that they can end their 
participation at any time without giving a reason. It will be emphasized that it will not impact their 
school results (grades). 

9 
 
The study has the potential to produce new knowledge about sleep problems and mental health in 
young people and to investigate the effects of a cost-effective universal prevention program 
integrated into regular school education that deals with sleep skills. Our goal is to find an effective 
way to prevent the development of sleep problems and promote mental health through better sleep 
among young people in a resource-efficient way because this could lead to better sleep habits, better 
mental health, and better school performance. These benefits will all positively impact society. 
The interventions (Sleep on Schedule and Technology restriction) have been carried out in similar 
versions among young people in the past without any negative effects reported. This is information 
that they can otherwise access through student health. 
Training the school staff to provide support to young people with sleep problems can also lead to 
benefits for future students who are not part of the research project. 
 
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