Introducing the College Sleep Questionnaire: A new pilot-tested formative assessment of student sleep.

Introducing the College Sleep Questionnaire: A new pilot-tested formative assessment of student sleep. Lisa Broek, M.A., Birdie Cunningham, M.A., Caitlin Kelly, B.S., J. Roxanne Prichard, Ph.D. ACHA 2014, 5/28/2014, WE3-186 Disclosures We have no financial disclosures to report. We are grateful to the ACHA for providing the Spring 2009 NCHA data set for analysis and to the ACHA UnitedHealthCare grant which funded this project. 1

Outline 1) Epidemic of Poor Sleep in College Students 2) Professional Practice Gap in Sleep Education 3) Need for a Formative Sleep Assessment for young adults 4) Development & Structure of the CSQ 5) CSQ Psychometrics & Comparison to Published Data 6) Scoring CSQ: 9 Profiles of Disturbed Sleep 7) Pilot use in a pre-post 2-campus intervention study 8) Next steps Sleep is at the base of Maslow s Hierarchy of Needs. 2

How many of the past 7 days did you get enough sleep so that you felt rested when you woke up in the morning? 40 35 30 25 20 15 UST National 10 5 0 0-1 days 2-3 days 4-5 days 6-7 days What are students saying about sleep? 3

Consequences of poor sleep in college students Lower Grades Increased Depression Dec. Immunity Inc. chance of W or F. Increased Stress & Anxiety Insulin Resistance Increased Accident Risk Increased interpersonal problems Increased BP Inc. Risk-Taking Behavior Inc. Suicidality Weight Gain 4

Poor sleep is a greater predictor of earning a lower grade or dropping a class than is binge drinking, marijuana use, physical illness. Sleep Problems by GPA D/F C B A -.20.00.20.40.60.80 1.00 Z-Score- Problems with Sleep Timing N=81,528 50% Any infectious illness in last 12 months 40% 30% 20% 10% 0 1 2 3 4 5 6 7 Last 7 days: Felt tired/sleepy during the day 5

40% 35% 30% 25% 20% 15% 10% 5% 0% % Ever Seriously Considered Suicide 0 days 1 day 2 days 3 days 4 days 5 days 6 days 7 days Last 7 days: Felt tired/sleepy during the day Outline 1) Epidemic of Poor Sleep in College Students 2) Professional Practice Gap in Sleep Education 3) Need for a Formative Sleep Assessment for young adults 4) Development & Structure of the CSQ 5) CSQ Psychometrics & Comparison to Published Data 6) Scoring CSQ: 9 Profiles of Disturbed Sleep 7) Pilot use in a pre-post 2-campus intervention study 8) Next steps 6

Insights from Spring 2013 NCHA 19.4% of students report that sleep difficulties negatively affecting academic performance. 26.9% report that sleep problems are traumatic or very difficult to handle 26% report receiving any information about sleep from their campus, yet 51% report wanting more information about achieving healthy sleep from their campuses. Sleep isn t high on the list of parents health concerns. 7

Sleep in America Poll 2014: Sleep in the Modern Family how today's modern family sets rules for sleep, navigates the use of technology in the bedroom, how parents can serve as sleep models for their family and make the dream of a "sleep healthy home" come true. Outline 1) Epidemic of Poor Sleep in College Students 2) Professional Practice Gap in Sleep Education 3) Need for a Formative Sleep Assessment for Young Adults 4) Development & Structure of the CSQ 5) CSQ Psychometrics & Comparison to Published Data 6) Scoring CSQ: 9 Profiles of Disturbed Sleep 7) Pilot use in a pre-post 2-campus intervention study 8) Next steps 8

Why do we need a new Sleep Questionnaire for college students? Most existing pediatric questionnaires aren t appropriate for young adults lives. Most adult questionnaires don t cover the primary sleep problems of young adults. Most sleep assessment instruments are focused on a particular aspect of sleep, rather than serving as a comprehensive, formative assessment. Both students and clinicians need more specific common dialogue for discussing sleep problems. Pediatric questionnaires don t extend to late adolescence. 9

Insomnia Severity Index www.myhealth.va.gov Charles M. Morin, Ph.D., Université Laval Insomnia Severity Index 10

Insomnia Severity Index Think about your vocabulary for healthy eating Are you as comfortable talking about sleep? 11

Outline 1) Epidemic of Poor Sleep in College Students 2) Professional Practice Gap in Sleep Education 3) Need for a Formative Sleep Assessment for Young Adults 4) Development & Structure of the College Sleep Questionnaire 5) CSQ Psychometric Data & Comparison to Published Data 6) Scoring CSQ: 9 Profiles of Disturbed Sleep 7) Pilot use in a pre-post 2-campus intervention study 8) Next steps Relevant Background Literature 12

Development Spruyt & Gozal (2011) Purpose We wanted to develop a screening tool for clinicians, researchers, and students to use to better identify and address sleep problems common among college students. This is not a clinical diagnostic tool; instead it s a screening measure to help identify when more in depth diagnostic tests might be necessary. The CSQ can give individualized feedback to each student regarding specific ways to improve sleep. 13

Development Process Literature review Discussion with psychologists, psychiatrists, sleep pulmonologists, college nursing staff members, college students Three rounds of pilot testing University of St. Thomas, Fall 2012 (n > 30) University of St. Thomas, Spring 2013 (n > 400) UST & Macalester College, Fall- Spring 2014 (n > 500) Statistical Concerns Reliability- test-retest consistency Validity- Test measures what you intend it to measure Sensitivity- Correctly identifies all who have particular trait (low false negatives) Specificity- Only identifies all who have particular trait (low false positives) 14

CSQ Format I. Mixture of open ended questions and likert scale II. Sleep disturbances are indicated by at least once a week designation III. Complete survey takes about 10 15 minutes to complete CSQ Content I. Motivations to change behavior & self-assessment of sleep disturbances II. Sleep Scheduling: Rise times, Bed times, all 7 days of the week, Sleep Latency, Sleep Inertia III. Sleepiness: Impairment in daytime functioning, drowsy driving IV. Sleep Disturbances (~30 questions) I. Physical II. Stress & Time Management III. Sleep Hygiene 15

CSQ Scoring We used principal component analysis to develop algorithms for detecting nine distinct clusters of sleep problems. Outline 1) Epidemic of Poor Sleep in College Students 2) Professional Practice Gap in Sleep Education 3) Need for a Formative Sleep Assessment for Young Adults 4) Development & Structure of the CSQ 5) CSQ Psychometrics & Comparison to Published Data 6) Scoring CSQ: 9 Profiles of Disturbed Sleep 7) Pilot use in a pre-post 2-campus intervention study 8) Next steps 16

How often do you arrange activities for optimal nighttime sleeping? 51% never/rarely 35% sometimes 11% most of the time 1% always What prevents you from getting the sleep you need? Academics 29% Social/Med 20% Extracurricular 14% Anxiety 10% Sleep Environment 9% Time Management 8% People 5% Physical 1% 17

Average Total Sleep Time Average Total Hours Average Sleep Latency (Min) 14% under 5 min. 57% 5 20 min. 28% >20 min. 18

National College Health Assessment Sleep Questions 1. Last 12 months diagnosed/treated: Insomnia 2. Last 12 months diagnosed/treated: Other sleep disorder 3. Last 12 months difficult to handle: Sleep difficulties 4. Academic performance negatively affected by sleep difficulties 5. Last 7 days: Enough sleep to feel rested 6. Last 7 days: Problem with sleepiness 7. Last 7 days: Awakened too early 8. Last 7 days: Felt tired/sleepy during the day 9. Last 7 days: Gone to bed because could not stay awake 10. Last 7 days: Extremely hard time falling asleep 11. Ever - Felt exhausted In the last week, how many days have you felt tired or sleepy during the day? ACHA Spring 2013 n=40,900 University of St. Thomas and Macalester 2013-2014 n=636 19

The Epworth Sleepiness Scale Sleep Disorders, Health, and Safety in Police Officers Rajarantam et al., JAMA, December 21, 2011, Vol 306, No. 23 n=3545 20

Students Epworth Sleepiness Scale The CSQ estimate of Excessive Daytime Sleepiness strongly correlates with ESS. Short Sleep Latency Long sleep inertia Naps Days Sleepy ESS TOTAL 21

Outline 1) Epidemic of Poor Sleep in College Students 2) Professional Practice Gap in Sleep Education 3) Need for a Formative Sleep Assessment for Young Adults 4) Development & Structure of the CSQ 5) CSQ Psychometrics & Comparison to Published Data 6) Scoring CSQ: 9 Profiles of Disturbed Sleep 7) Pilot use in a pre-post 2-campus intervention study 8) Next steps 1. Insufficient Sleep (Somnorexia) 22

1. Insufficient Sleep (Somnorexia) Short sleep latency Sleep less than 7 hours a night Excessive Sleepiness 24% of sample population 2. Sleep Disordered Breathing A Tool to Screen Patients for Obstructive Sleep Apnea. Chung, et al. Anesthesiology 2008; 108:812 21 Copyright 2008, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. 23

2. Sleep Disordered Breathing AM Headaches Told about snoring Excessive Sleepiness 5.5% of sample population 3. Narcolepsy 60% of patients were initially misdiagnosed. The most common misdiagnosis was depression, followed by insomnia and obstructive sleep apnea. (Patients Journeys to a Narcolepsy Diagnosis; Lawrence P Carter, PhD, Christine Acebo, PhD, AnnY Kim, MA) 24

3. Narcolepsy Feel rubbery with strong emotions See / feel things that may not be real upon awakening Excessive Daytime Sleepiness Nightmares 3% of sample population 4. Restless Leg Syndrome 25

4. Restless Legs Syndrome Itching feeling in legs when trying to fall asleep Long sleep latency Can t relax body for sleep 5.7% of sample population 5. Circadian Misalignment 26

5. Circadian Misalignment Long sleep latency Not tired when time for bed Can t relax body Evening chronotype Late midsleep 3% of sample population 6. Probable Mood Disorder 27

6. Probable Mood Disorder Feeling over-extended Trouble relaxing body Racing thoughts Sleep onset insomnia Sleep maintenance insomnia Nightmares 14% of sample population 7. Poor Time Management 28

7. Poor Time Management Doesn t arrange schedule for sleep Can t keep track of things to do Stays up later than planned to complete tasks 14% of population 8. Probable Stimulant Sedation Loop Problems 29

8. Probable Stimulant Sedation Loop / Substance Use Problems Uses stimulants to wake up Uses depressants to fall asleep 20% of population 9. Poor Sleep Hygiene 30

9. Poor sleep hygiene Not turning off phone Not arranging schedule to optimize sleeping Using electronics before bed Keeping an irregular weekweekend schedule Any Identified Probable Sleep Problem 57% had at least 1 identified probable sleep problem. Those without any identified sleep problem had higher GPAs (p =.06), less daytime sleepiness. 31

Outline 1) Epidemic of Poor Sleep in College Students 2) Professional Practice Gap in Sleep Education 3) Need for a Formative Sleep Assessment for Young Adults 4) Development & Structure of the CSQ 5) CSQ Psychometrics & Comparison to Published Data 6) Scoring CSQ: 9 Profiles of Disturbed Sleep 7) Pilot use in a pre-post 2-campus intervention study 8) Next steps Intervention: Sleep Squad 32

Wellness Center Sleep Squad Program Sent out request emails to targeted faculty, coaches, organizations Hired a student worker dedicated to Sleep Squad Set up Sleep Squad schedule Outreach 21 Classrooms 437 Students 4 Athletic Teams 145 students Campus Peer Ministry Students and Wellness Center Student Workers Student Health Service Staff and Counseling and Psychological Services Sleep Squad Results Students were: more willing to change their sleep habits, t(129)=-3.5, p<0.001 feeling less sleepy, t(128)=2.3, p<0.03 going to sleep earlier on weekends, t(113)=2.4, p<0.02 decreased Epworth Sleepiness Scale score, t(129)=4.3, p<0.001 33

Improvements in Stages of Change PRE POST What one or two things are you willing to change to improve your sleep in the next month? Sleep Timing/Extension 36% Sleep Environment/Routine 33% Time Management 27% Limit Caffeine 4% 34

Macalester College, St. Paul, MN Small, private liberal arts college (enrollment of 2,000) Highly selective Two year residency requirement Student/faculty ratio of 10 to 1 2 out of 3 students study abroad most for at least 12 weeks FIRST-YEAR COURSE SLEEP PROJECT Pilot Fall 2011 4 first-year courses = 2 control, 2 education Met 5 times total over semester Pre-test (first week of classes) Three 10-minute sessions throughout semester Reinforcement of message by professor Post-test (end of semester, right before finals) Year 3 Fall 2013 12 first-year courses receiving education 3 times a semester Pre-post Design Year 2 Fall 2012 8 first-year courses all receiving education 35

Average 5/30/2014 Last 7 Days: Gotten enough sleep to feel rested next morning 4 3.5 3 2.5 2 1.5 1 0.5 0 2.8 2.9 3 3.1 3 2.6 1.7 2011 Control n= 32 2011 Program n=32 2012 n=128 3.5 2013 n=201 Pre Post Trends found after Macalester curriculum infusion program More days enough sleep Less days up too early Getting to sleep at more consistent bedtimes More likely to change their sleep patterns Lower score on Epworth Sleepiness Scale Students sleeping habits did not get worse, which is a HUGE success!! 36

Outline 1) Epidemic of Poor Sleep in College Students 2) Professional Practice Gap in Sleep Education 3) Need for a Formative Sleep Assessment for Young Adults 4) Development & Structure of the CSQ 5) CSQ Psychometrics & Comparison to Published Data 6) Scoring CSQ: 9 Profiles of Disturbed Sleep 7) Pilot use in a pre-post 2-campus intervention study 8) Next steps College Sleep Questionnaire Working with software developers to make the CSQ tool online, and individualized to campuses. For more information about the CSQ, please add your name to the sign up sheet. 37

QUESTIONS? @RoxannePrichard jrprichard@stthomas.edu 38