What is the recommended management of sleep difficulty in adolescents and young adults (ages 12‑25)?

Management of Sleep Difficulty in Youth (Ages 12-25)

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

Cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment for sleep difficulties in adolescents and young adults, delivered over 4-8 sessions by a trained clinician, with effects sustained for up to 2 years without medication-related risks. 1

Core Components of CBT-I

Sleep Restriction Therapy:

• Have the adolescent maintain a sleep log for 1-2 weeks to calculate mean total sleep time (TST) 1
• Initially limit time in bed to match TST (minimum 5 hours) to achieve >85% sleep efficiency (TST/time in bed × 100%) 1
• Gradually increase time in bed by 15-20 minutes every 5 days as sleep efficiency improves 2
• This temporarily increases daytime fatigue but resolves by end of treatment 1

Stimulus Control Therapy:

• Use the bedroom only for sleep and sex—no television, homework, or phone use in bed 2, 1
• Leave the bedroom if unable to fall asleep within 15-20 minutes and return only when sleepy 1
• Maintain consistent sleep and wake times every day, including weekends 2, 1
• Avoid daytime napping; if necessary, limit to 30 minutes before 2 PM 2

Cognitive Therapy:

• Identify and challenge dysfunctional beliefs such as "I need 8 hours or I won't function" or "My life will be ruined if I can't sleep" 1, 3
• Address catastrophic thinking about sleep loss that perpetuates anxiety and insomnia 1

Relaxation Training:

• Teach progressive muscle relaxation (tensing and relaxing each muscle group sequentially) 2, 1
• Practice guided imagery or diaphragmatic breathing to reduce arousal before bedtime 2, 1
• Develop a 30-minute pre-bedtime relaxation ritual 2

Sleep Hygiene Education:

• Avoid caffeine, nicotine, and alcohol, especially in the evening 2, 3, 4
• Avoid heavy exercise within 2 hours of bedtime 2, 3
• Keep the bedroom cool, dark, and quiet 1, 3
• Remove electronic devices from the bedroom at least 1 hour before bedtime 4, 5

Adolescent-Specific Contributing Factors to Address

Biological Factors:

• Recognize that puberty causes a normal circadian rhythm delay, making adolescents naturally inclined to later sleep and wake times 6, 4
• Understand that developmentally-based slowing of the "sleep drive" contributes to difficulty falling asleep 6

Behavioral and Environmental Factors:

• Address excessive homework load and extracurricular activities that delay bedtime 6, 7
• Limit evening use of electronic media and social media, which perpetuates "social jetlag" and chronic sleep deprivation 6, 4, 5
• Reduce caffeine intake, particularly energy drinks and caffeinated sodas 6, 4
• Discuss the impact of early school start times on insufficient sleep 6, 4

Psychosocial Stressors:

• Screen for stress related to academic pressure, social relationships, and existential concerns 7
• Evaluate for mood disturbances, including depression and anxiety, which both contribute to and result from sleep difficulties 6, 4

Consequences of Untreated Sleep Difficulties in Youth

Academic and Cognitive:

• Inattentiveness, reduced executive functioning, and poor academic performance 6, 4
• Impaired memory consolidation and learning 6

Mental Health:

• Increased risk of depression, anxiety, and suicidal ideation 2, 6, 4
• Altered mood regulation and emotional dysregulation 6, 5

Physical Health:

• Increased risk of obesity and cardiometabolic dysfunction 2, 6, 4
• Consumption of more carbohydrates, added sugars, and sweet drinks with fewer fruits and vegetables 2

Safety:

• Higher rates of motor vehicle crashes, occupational injuries, and sports-related injuries 6, 4
• Increased engagement in health risk behaviors including alcohol and substance use 6, 4

When to Consider Pharmacotherapy

Pharmacological therapy should only be considered after CBT-I alone has been unsuccessful, using shared decision-making to discuss benefits, harms, and costs of short-term medication use. 1, 8

Appropriate Medication Options (if CBT-I fails):

• For sleep onset difficulty: ramelteon 8 mg at bedtime or short-acting zolpidem (dose adjusted for age/weight) 1
• For sleep maintenance difficulty: low-dose doxepin (3-6 mg) or suvorexant 1, 8
• Medications should be used intermittently (3 nights per week) or as needed, not daily 3

Medications to Avoid in Adolescents and Young Adults:

• Never use benzodiazepines (triazolam, temazepam, lorazepam, clonazepam) due to risks of dependence, cognitive impairment, and potential for abuse 1, 8, 3
• Avoid over-the-counter antihistamines (diphenhydramine, hydroxyzine) due to anticholinergic effects and lack of efficacy data 1, 8, 3
• Do not use sedating antidepressants (trazodone, mirtazapine, amitriptyline) unless comorbid depression exists, as evidence for primary insomnia is weak 1, 8, 3
• Avoid herbal supplements (valerian, melatonin) due to lack of efficacy and safety data in this population 1

Family and School Interventions

Family-Level Strategies:

• Establish unpopular but necessary boundaries on technology use, with parental commitment to enforce limits 5
• Foster family-wide healthy sleep practices, as parental modeling influences adolescent behavior 5
• Develop rapport with the adolescent to gain insight into problems associated with chronic sleep deficiency 5

School-Level Strategies:

• Advocate for later school start times to align with adolescent circadian biology 6, 4
• Provide healthy sleep education for students and families through school health services 6, 4
• Connect adolescents with school nurses for ongoing support and monitoring 7

Critical Pitfalls to Avoid

• Never initiate pharmacotherapy before attempting CBT-I, as behavioral interventions provide superior long-term outcomes and avoid medication-related risks including dependence and rebound insomnia 1, 3
• Do not assume sleep hygiene education alone will suffice—it must be combined with other CBT-I modalities (sleep restriction, stimulus control, cognitive therapy) to be effective 1, 3
• Do not dismiss adolescent sleep complaints as "normal teenage behavior"—chronic sleep deprivation has serious consequences for health, safety, and academic performance 6, 4, 5
• Avoid focusing solely on sleep duration—consider the entire 24-hour day including physical activity, sedentary time, and eating patterns, as these interact to influence sleep quality 2

Monitoring and Follow-Up

• Maintain a sleep diary throughout treatment to track sleep onset latency, wake after sleep onset, total sleep time, and sleep efficiency 1, 8, 3
• Schedule follow-up every 2-4 weeks initially, then monthly until stabilization 8, 3
• Reassess for comorbid conditions including sleep apnea, depression, and anxiety if CBT-I is ineffective 8