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A Pilot Randomized Controlled Trial of Cognitive-Behavioral Therapy for Insomnia in Adolescents With Persistent Postconcussion Symptoms

Tomfohr-Madsen, Lianne PhD; Madsen, Joshua W. PhD; Bonneville, Dominique BA; Virani, Shane MSc; Plourde, Vickie PhD; Barlow, Karen M. MBChB, MSc, MRCPCH (UK); Yeates, Keith Owen PhD; Brooks, Brian L. PhD

The Journal of Head Trauma Rehabilitation: June 25, 2019 - Volume Publish Ahead of Print - Issue - p
doi: 10.1097/HTR.0000000000000504
Original Article: PDF Only

Objective: Cognitive-behavioral therapy for insomnia (CBT-I) is an effective insomnia treatment but has yet to be applied to adolescents with sleep disruption following concussion. This pilot study evaluated CBT-I to improve insomnia in adolescents with protracted concussion recovery.

Setting: Tertiary pediatric hospital.

Participants: Participants (N = 24) were 12 to 18 years old (M = 15.0, SD = 1.4), 15.1 weeks (SD = 9.2) postinjury, and presenting with sleep disruption and persistent postconcussion symptoms.

Design: A single-blind, parallel-group randomized controlled trial (RCT) design comparing 6 weeks of CBT-I and a treatment-as-usual control group. Outcomes were measured before treatment, at treatment completion, and 4 weeks after completion.

Main Measures: Primary outcome was Insomnia Severity Index. Secondary outcomes included Pittsburgh Sleep Quality Index, Dysfunctional Beliefs and Attitudes about Sleep Scale, 7-night sleep diary, PROMIS Depression, PROMIS Anxiety, and Health and Behavior Inventory.

Results: Adolescents who received CBT-I demonstrated large and clinically significant improvements in insomnia ratings at posttreatment that were maintained at follow-up. They also reported improved sleep quality, fewer dysfunctional beliefs about sleep, better sleep efficiency, shorter sleep-onset latency, and longer sleep time compared with those with treatment as usual. There was also a modest reduction in postconcussion symptoms.

Conclusion: In this pilot RCT, 6 weeks of CBT-I produced significant improvement in sleep in adolescents with persistent postconcussion symptoms. A larger trial is warranted.

Departments of Psychology (Drs Tomfohr-Madsen, Madsen, Yeates, & Brooks) Psychiatry (Ms Bonneville), and Faculty of Kinesiology (Mr Virani), University of Calgary, Calgary, Alberta, Canada; Faculté St Jean, University of Alberta, Edmonton, Alberta, Canada (Dr Plourde); Neuropsychology Service, Alberta Children's Hospital, Calgary, Alberta, Canada (Mr Virani and Dr Brooks); Faculty of Medicine, University of Queensland, Brisbane, New South Wales, Australia (Dr Barlow); Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada (Drs Tomfohr-Madsen, Yeates, Brooks, and Barlow); Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada (Drs Tomfohr-Madsen, Yeates, and Brooks and Mr Virani); Hotchkiss Brain Institute, Calgary, Alberta, Canada (Drs Yeates and Brooks); and Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada (Drs Yeates and Brooks).

Corresponding Author: Brian L. Brooks, PhD, Alberta Children's Hospital, 28 Oki Drive NW, Calgary, AB T3B 6A8, Canada (

This project was funded by the University of Calgary's Cumming School of Medicine Clinical Research Fund (CRF15-010) awarded to Brian Brooks (principal investigator; coinvestigators: Lianne Tomfohr-Madsen, Keith Owen Yeates, and Karen Barlow). Salary support for Brian Brooks was provided by the CIHR Embedded Clinical Research Award. Salary support for Lianne Tomfohr-Madsen was provided by the Canadian Child Health Clinician Scientist Program. Keith Owen Yeates is supported by the Ronald and Irene Ward Chair in Pediatric Brain Injury at the University of Calgary. The authors thank the families at Alberta Children's Hospital for agreeing to participate in this clinical trial, the clinical trial nurse, nurses, and nurse practitioners in the Alberta Children's Hospital Brain Injury Clinic who facilitated recruitment (Heather Godfrey, Lisa Bodell, Lisette Lockyer, and Sarah Schantz), and the PhD student clinicians who provided the treatment (Ivan Sedov, Emily Cameron, Briana Cassetta, Jessica Switzer, and Jenna Thomas).

Brian Brooks receives royalties for the sales of the Pediatric Forensic Neuropsychology textbook (2012, Oxford University Press) and 3 pediatric neuropsychological tests (Child and Adolescent Memory Profile [ChAMP, Sherman and Brooks, 2015, PAR Inc], Memory Validity Profile [MVP, Sherman and Brooks, 2015, PAR Inc], and Multidimensional Everyday Memory Ratings for Youth [MEMRY, Sherman and Brooks, 2017, PAR Inc]). He previously received in-kind support (free test credits) from the publisher of a computerized cognitive test (CNS Vital Signs, Chapel Hill, North Carolina) for prior studies. Keith Yeates receives royalties for book sales from the Guilford Press and Cambridge University Press and occasionally serves as a paid expert in forensic cases. He is codeveloper of the Health and Behavior Inventory, which is a public domain questionnaire. None of the authors have a financial interest in any measures used in the present study.; Identifier: NCT03688984 (

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The authors declare no conflicts of interest.

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