Evaluation of an interactive school-based sleep education program: a cluster-randomized controlled trial.

OBJECTIVES: Shortened sleep has negative consequences on adolescents' well-being. The present study evaluated an interactive school-based sleep education program (SEP) aimed at increasing adolescent sleep duration. DESIGN AND INTERVENTION: A cluster-randomized controlled trial with 12 clusters (classes) was used. The intervention group received a SEP and the active control group received a healthy living program (HLP). Both groups underwent a 4-week class-based education program. The SEP students learned about the importance of sleep, the barriers to getting enough sleep, and how to improve their time management to increase their sleep opportunity. The HLP students learned about various health-related topics not including sleep. PARTICIPANTS: A total of 210 students (mean age = 14.04 ± 0.32 years) were randomly assigned to the SEP (n = 102) or the HLP (n = 108) group, with 6 classes per group. MEASUREMENTS: Sleep (actigraphically measured), sleep knowledge, and time usage were assessed using linear mixed models at three time points: baseline, immediately after intervention, and 1-month follow-up. RESULTS: Sleep knowledge improved at follow-up in the SEP relative to the HLP group (p = .017). Although students were receptive of the program and self-reported the intention to create more time for sleep, no changes in sleep were found following the SEP. Some benefit may have been masked by exam preparations at the follow-up evaluation. CONCLUSIONS: Sleep education alone may not be sufficient to change sleep behavior. A combination of sleep education, starting school later, and parental involvement may be needed to encourage and enable changes in adolescent sleep duration.

Associations of sleep duration on school nights with self-rated health, overweight, and depression symptoms in adolescents: problems and possible solutions.

OBJECTIVE: To investigate associations between sleep duration and health-related measures, and factors associated with short sleep, in adolescents in an East Asian society with strong emphasis on academic achievement. METHODS: Adolescents aged 13-19 years (n = 2346) from eight schools in Singapore (five local, three international) took part in a cross-sectional survey of sleep habits, school life, and health. Self-rated health, overweight (International Obesity Task Force Criteria), and depression symptoms were compared in adolescents with short (<7 h), moderately short (7 to <8 h), or an appropriate amount of sleep (8-10 h) on school nights. RESULTS: Short sleep on school nights was associated with poorer self-rated health, increased odds of being overweight (adjusted odds ratio [ORadj] = 2.56, 95% confidence interval = 1.39-4.70), and increased odds of feeling depression symptoms (sadness, irritability, worthlessness, low motivation, difficulty concentrating, anhedonia, anxiety, and thoughts of self-harm/suicide) compared with an appropriate sleep duration (ORadj = 2.10-4.33, p < 0.05 for each symptom). Barriers to healthy sleep included later preferred sleep timing (a relative indicator of later chronotype), lower parental supervision of bedtime, longer study time, early school start time, and longer travel time. Students at local schools were less likely to have a parent-set bedtime, and spent more time on homework/studying. Later bedtime in local schools attenuated the benefit of later school start time on nocturnal sleep duration. CONCLUSIONS: Short sleep may contribute to poorer adolescent health and well-being. Strategies for improving sleep in hard-driving East Asian societies should take into account sociocultural factors that may impede removal of barriers to healthy sleep.

Sustained benefits of delaying school start time on adolescent sleep and well-being.

Study Objectives: To investigate the short- and longer-term impact of a 45-min delay in school start time on sleep and well-being of adolescents. Methods: The sample consisted of 375 students in grades 7-10 (mean age ± SD: 14.6 ± 1.15 years) from an all-girls' secondary school in Singapore that delayed its start time from 07:30 to 08:15. Self-reports of sleep timing, sleepiness, and well-being (depressive symptoms and mood) were obtained at baseline prior to the delay, and at approximately 1 and 9 months after the delay. Total sleep time (TST) was evaluated via actigraphy. Results: After 1 month, bedtimes on school nights were delayed by 9.0 min, while rise times were delayed by 31.6 min, resulting in an increase in time in bed (TIB) of 23.2 min. After 9 months, the increase in TIB was sustained, and TST increased by 10.0 min relative to baseline. Participants also reported lower levels of subjective sleepiness and improvement in well-being at both follow-ups. Notably, greater increase in sleep duration on school nights was associated with greater improvement in alertness and well-being. Conclusions: Delaying school start time can result in sustained benefits on sleep duration, daytime alertness, and mental well-being even within a culture where trading sleep for academic success is widespread.

Neurobehavioral Impact of Successive Cycles of Sleep Restriction With and Without Naps in Adolescents.

Study Objectives: To characterize adolescents' neurobehavioral changes during two cycles of restricted and recovery sleep and to examine the effectiveness of afternoon naps in ameliorating neurobehavioral deficits associated with multiple nights of sleep restriction. Methods: Fifty-seven healthy adolescents (aged 15-19 years; 31 males) participated in a parallel group study. They underwent two cycles of sleep restriction (5-hr time in bed [TIB] for five and three nights in the first and the second cycles, respectively; 01:00-06:00) and recovery (9-hr TIB for two nights per cycle; 23:00-08:00) intended to simulate the weekday sleep loss and weekend attempt to "catch up" on sleep. Half of the participants received a 1-hr nap opportunity at 14:00 following each sleep-restricted night, while the other half stayed awake. Sustained attention, sleepiness, speed of processing, executive function, and mood were assessed 3 times each day. Results: Participants who were not allowed to nap showed progressive decline in sustained attention that did not return to baseline after two nights of recovery sleep. Exposure to the second period of sleep restriction increased the rate of vigilance deterioration. Similar patterns were found for other neurobehavioral measures. Napping attenuated but did not eliminate performance decline. These findings contrasted with the stable performance of adolescents, given 9-hr TIB each night in our recent study. Conclusions: Adolescents' neurobehavioral functions may not adapt to successive cycles of sleep curtailment and recovery. In sleep-restricted adolescents, weekend "catch-up sleep," even when combined with napping during weekdays, is inferior to receiving a 9-hr sleep opportunity each night.

Functional Heterogeneity and Convergence in the Right Temporoparietal Junction.

The right temporoparietal junction (rTPJ) is engaged by tasks that manipulate biological motion processing, Theory of Mind attributions, and attention reorienting. The proximity of activations elicited by these tasks raises the question of whether these tasks share common cognitive component processes that are subserved by common neural substrates. Here, we used high-resolution whole-brain functional magnetic resonance imaging in a within-subjects design to determine whether these tasks activate common regions of the rTPJ. Each participant was presented with the 3 tasks in the same imaging session. In a whole-brain analysis, we found that only the right and left TPJs were activated by all 3 tasks. Multivoxel pattern analysis revealed that the regions of overlap could still discriminate the 3 tasks. Notably, we found significant cross-task classification in the right TPJ, which suggests a shared neural process between the 3 tasks. Taken together, these results support prior studies that have indicated functional heterogeneity within the rTPJ but also suggest a convergence of function within a region of overlap. These results also call for further investigation into the nature of the function subserved in this overlap region.

Neural regions discriminating contextual information as conveyed through the learned preferences of others.

The human brain consists of a network of regions that are engaged when one observes the movements of others. Observing unexpected movements, as defined by the context, often elicits greater activity, particularly in the right posterior superior temporal sulcus (pSTS). This implies that observers use contextual information to form expectations about an agent's goal and subsequent movements. The current study sought to identify regions that support the formation of these context-dependent expectations, with the pSTS being one candidate, given the consistent contextual modulation of its activity. We presented participants with fictitious individuals who had emotion-dependent food preferences, and instructed participants to indicate which food they expected each individual to choose based on the individual's current emotional state. Each individual's preference and emotional state therefore created a context that informed the observer's expectation of the individual's choice. Multi-voxel pattern analysis (MVPA) was used to assess if these different contexts could be discriminated in the pSTS and elsewhere in the brain. No evidence for context discrimination was found in the pSTS. Context discrimination was found instead a network of other brain regions including the anterior medial prefrontal cortex (amPFC), bilateral parietal cortex, left middle temporal gyrus (L MTG) and left anterior temporal lobe (L ATL), which have been previously associated with context processing, and semantic and memory retrieval. All together, these regions possibly support the formation of context-dependent expectations of an agent's goal.

Discriminable spatial patterns of activation for faces and bodies in the fusiform gyrus.

Functional neuroimaging studies consistently report that the visual perception of faces and bodies strongly activates regions within ventral occipitotemporal cortex (VOTC) and, in particular, within the mid-lateral fusiform gyrus. One unresolved issue is the degree to which faces and bodies activate discrete or overlapping cortical regions within this region. Here, we examined VOTC activity to faces and bodies at high spatial resolution, using univariate and multivariate analysis approaches sensitive to differences in both the strength and spatial pattern of activation. Faces and bodies evoked substantially overlapping activations in the fusiform gyrus when each was compared to the control category of houses. No discrete regions of activation for faces and bodies in the fusiform gyrus survived a direct statistical comparison using standard univariate statistics. However, multi-voxel pattern analysis differentiated faces and bodies in regions where univariate analysis found no significant difference in the strength of activation. Using a whole-brain multivariate searchlight approach, we also found that extensive regions in VOTC beyond those defined as fusiform face and body areas using standard criteria where the spatial pattern of activation discriminated faces and bodies. These findings provide insights into the spatial distribution of face- and body-specific activations in VOTC and the identification of functionally specialized regions.

Attributing intentions to random motion engages the posterior superior temporal sulcus.

The right posterior superior temporal sulcus (pSTS) is a neural region involved in assessing the goals and intentions underlying the motion of social agents. Recent research has identified visual cues, such as chasing, that trigger animacy detection and intention attribution. When readily available in a visual display, these cues reliably activate the pSTS. Here, using functional magnetic resonance imaging, we examined if attributing intentions to random motion would likewise engage the pSTS. Participants viewed displays of four moving circles and were instructed to search for chasing or mirror-correlated motion. On chasing trials, one circle chased another circle, invoking the percept of an intentional agent; while on correlated motion trials, one circle's motion was mirror reflected by another. On the remaining trials, all circles moved randomly. As expected, pSTS activation was greater when participants searched for chasing vs correlated motion when these cues were present in the displays. Of critical importance, pSTS activation was also greater when participants searched for chasing compared to mirror-correlated motion when the displays in both search conditions were statistically identical random motion. We conclude that pSTS activity associated with intention attribution can be invoked by top-down processes in the absence of reliable visual cues for intentionality.

Local and long-range functional connectivity is reduced in concert in autism spectrum disorders.

Long-range cortical functional connectivity is often reduced in autism spectrum disorders (ASD), but the nature of local cortical functional connectivity in ASD has remained elusive. We used magnetoencephalography to measure task-related local functional connectivity, as manifested by coupling between the phase of alpha oscillations and the amplitude of gamma oscillations, in the fusiform face area (FFA) of individuals diagnosed with ASD and typically developing individuals while they viewed neutral faces, emotional faces, and houses. We also measured task-related long-range functional connectivity between the FFA and the rest of the cortex during the same paradigm. In agreement with earlier studies, long-range functional connectivity between the FFA and three distant cortical regions was reduced in the ASD group. However, contrary to the prevailing hypothesis in the field, we found that local functional connectivity within the FFA was also reduced in individuals with ASD when viewing faces. Furthermore, the strength of long-range functional connectivity was directly correlated to the strength of local functional connectivity in both groups; thus, long-range and local connectivity were reduced proportionally in the ASD group. Finally, the magnitude of local functional connectivity correlated with ASD severity, and statistical classification using local and long-range functional connectivity data identified ASD diagnosis with 90% accuracy. These results suggest that failure to entrain neuronal assemblies fully both within and across cortical regions may be characteristic of ASD.

Impaired theory of mind for moral judgment in high-functioning autism.

High-functioning autism (ASD) is characterized by real-life difficulties in social interaction; however, these individuals often succeed on laboratory tests that require an understanding of another person's beliefs and intentions. This paradox suggests a theory of mind (ToM) deficit in adults with ASD that has yet to be demonstrated in an experimental task eliciting ToM judgments. We tested whether ASD adults would show atypical moral judgments when they need to consider both the intentions (based on ToM) and outcomes of a person's actions. In experiment 1, ASD and neurotypical (NT) participants performed a ToM task designed to test false belief understanding. In experiment 2, the same ASD participants and a new group of NT participants judged the moral permissibility of actions, in a 2 (intention: neutral/negative) × 2 (outcome: neutral/negative) design. Though there was no difference between groups on the false belief task, there was a selective difference in the moral judgment task for judgments of accidental harms, but not neutral acts, attempted harms, or intentional harms. Unlike the NT group, which judged accidental harms less morally wrong than attempted harms, the ASD group did not reliably judge accidental and attempted harms as morally different. In judging accidental harms, ASD participants appeared to show an underreliance on information about a person's innocent intention and, as a direct result, an overreliance on the action's negative outcome. These findings reveal impairments in integrating mental state information (e.g., beliefs, intentions) for moral judgment.

Dissociable neural systems supporting knowledge about human character and appearance in ourselves and others.

Functional neuroimaging has identified a neural system comprising posterior cingulate (pCC) and medial prefrontal (mPFC) cortices that appears to mediate self-referential thought. It is unclear whether the two components of this system mediate similar or different psychological processes, and how specific this system is for self relative to others. In an fMRI study, we compared brain responses for evaluation of character (e.g., honest) versus appearance (e.g., svelte) for oneself, one's mother (a close other), and President Bush (a distant other). There was a double dissociation between dorsal mPFC, which was more engaged for character than appearance judgments, and pCC, which was more engaged for appearance than character judgments. A ventral region of mPFC was engaged for judgments involving one's own character and appearance, and one's mother's character, but not her appearance. A follow-up behavioral study indicated that participants rate their own character and appearance, and their mother's character, but not her appearance, as important in their self-concept. This suggests that ventral mPFC activation reflects its role in processing information relevant to the self, but not limited to the self. Thus, specific neural systems mediate specific aspects of thinking about character and appearance in oneself and in others.

The posterior superior temporal sulcus is sensitive to the outcome of human and non-human goal-directed actions.

Prior studies have demonstrated that the posterior superior temporal sulcus (pSTS) is involved in analyzing the intentions underlying actions and is sensitive to the context within which actions occur. However, it is debated whether the pSTS is actually sensitive to goals underlying actions, or whether previous studies can be interpreted to suggest that the pSTS is instead involved in the allocation of visual attention towards unexpected events. In addition, little is known about whether the pSTS is specialized for reasoning about the actions of social agents or whether the pSTS is sensitive to the actions of both animate and inanimate entities. Here, using functional magnetic resonance imaging, we investigated activation in response to passive viewing of successful and unsuccessful animate and inanimate goal-directed actions. Activation in the right pSTS was stronger in response to failed actions compared to successful actions, suggesting that the pSTS plays a role in encoding the goals underlying actions. Activation in the pSTS did not differentiate between animate and inanimate actions, suggesting that the pSTS is sensitive to the goal-directed actions of both animate and inanimate entities.

An anterior-to-posterior shift in midline cortical activity in schizophrenia during self-reflection.

BACKGROUND: Deficits in social cognition, including impairments in self-awareness, contribute to the overall functional disability associated with schizophrenia. Studies in healthy subjects have shown that social cognitive functions, including self-reflection, rely on the medial prefrontal cortex (mPFC) and posterior cingulate gyrus, and these regions exhibit highly correlated activity during "resting" states. In this study, we tested the hypothesis that patients with schizophrenia show dysfunction of this network during self-reflection and that this abnormal activity is associated with changes in the strength of resting-state correlations between these regions. METHODS: Activation during self-reflection and control tasks was measured with functional magnetic resonance imaging in 19 patients with schizophrenia and 20 demographically matched control subjects. In addition, the resting-state functional connectivity of midline cortical areas showing abnormal self-reflection-related activation in schizophrenia was measured. RESULTS: Compared with control subjects, the schizophrenia patients demonstrated lower activation of the right ventral mPFC and greater activation of the mid/posterior cingulate gyri bilaterally during self-reflection, relative to a control task. A similar pattern was seen during overall social reflection. In addition, functional connectivity between the portion of the left mid/posterior cingulate gyrus showing abnormally elevated activity during self-reflection in schizophrenia, and the dorsal anterior cingulate gyrus was lower in the schizophrenia patients compared with control subjects. CONCLUSIONS: Schizophrenia is associated with an anterior-to-posterior shift in introspection-related activation, as well as changes in functional connectivity, of the midline cortex. These findings provide support for the hypothesis that aberrant midline cortical function contributes to social cognitive impairment in schizophrenia.

Neural signatures of autism.

Functional magnetic resonance imaging of brain responses to biological motion in children with autism spectrum disorder (ASD), unaffected siblings (US) of children with ASD, and typically developing (TD) children has revealed three types of neural signatures: (i) state activity, related to the state of having ASD that characterizes the nature of disruption in brain circuitry; (ii) trait activity, reflecting shared areas of dysfunction in US and children with ASD, thereby providing a promising neuroendophenotype to facilitate efforts to bridge genomic complexity and disorder heterogeneity; and (iii) compensatory activity, unique to US, suggesting a neural system-level mechanism by which US might compensate for an increased genetic risk for developing ASD. The distinct brain responses to biological motion exhibited by TD children and US are striking given the identical behavioral profile of these two groups. These findings offer far-reaching implications for our understanding of the neural systems underlying autism.

Cortical integration of audio-visual speech and non-speech stimuli.

Using fMRI we investigated the neural basis of audio-visual processing of speech and non-speech stimuli using physically similar auditory stimuli (speech and sinusoidal tones) and visual stimuli (animated circles and ellipses). Relative to uni-modal stimuli, the different multi-modal stimuli showed increased activation in largely non-overlapping areas. Ellipse-Speech, which most resembles naturalistic audio-visual speech, showed higher activation in the right inferior frontal gyrus, fusiform gyri, left posterior superior temporal sulcus, and lateral occipital cortex. Circle-Tone, an arbitrary audio-visual pairing with no speech association, activated middle temporal gyri and lateral occipital cortex. Circle-Speech showed activation in lateral occipital cortex, and Ellipse-Tone did not show increased activation relative to uni-modal stimuli. Further analysis revealed that middle temporal regions, although identified as multi-modal only in the Circle-Tone condition, were more strongly active to Ellipse-Speech or Circle-Speech, but regions that were identified as multi-modal for Ellipse-Speech were always strongest for Ellipse-Speech. Our results suggest that combinations of auditory and visual stimuli may together be processed by different cortical networks, depending on the extent to which multi-modal speech or non-speech percepts are evoked.

The effectiveness of hospital-based diabetes case management: an example from a northern Taiwan regional hospital.

The aim of this study was to design, implement and evaluate disease outcomes at a regional hospital- based case management program of care for patients with type 2 diabetes. A medical team and practice guidelines were established in line with the health insurance strategy of Taiwan's Bureau of National Health Insurance (BNHI) and American Diabetes Association (ADA) Standards of Care for Diabetes (2003 edition). Also, a set of self-care booklets was designed suitable for use by the subject group. The study was prospective and followed the patients from enrollment to one year. Patient outcomes were determined based on laboratory examinations and recorded self-care behavior. Data were collected at enrollment and over 4 follow-up times within a one year period. Generalized Estimating Equation (GEE) multiple linear regression and logistic regression were used for repeated measurements and adjustments of the effects of specific prognostic factors. Sixty subjects diagnosed with type 2 diabetes (mean duration 3.25 years) were recruited. All participants were married with a mean age of 52.5 years. A majority (58.3%) was male and 65% were ethnic Hakka. Self-care knowledge and behavior accomplishment rates were: taking medications by oneself, 91.3% (knowing medicines, 25.4%); hypoglycemia management, 23.3%; monitoring blood sugar, 46.7%; exercise, 35.8%; diet management, 51.7% and foot care, 92.8%. Significantly improved ADA diabetes care standard items included HbA1C (p< .0001), fasting glucose (p< .01) and triglycerides (p< .05). The study incorporated evidence-based guidelines, public health insurance strategies and self-care booklets into a protocol to provide comprehensive care. The implemented diabetes program achieved diabetes care goals and improved patient self-care.