Violence among Adolescents Is a Substantial Public-health Concern. Homicide Is Currently the Second Leading Cause of Death in This Age

VIOLENCE AMONG ADOLESCENTS IS A SUBSTANTIAL PUBLIC-HEALTH CONCERN. HOMICIDE IS CURRENTLY THE SECOND LEADING CAUSE OF DEATH IN THIS AGE group.1 Recently, research has focused on emotional dysregulation as a predictor of aggression and violence in adolescents.2,3 Aggressive adolescents may be less able to inhibit impulses, urges, or strong affect4 and, thus, act out on anger-related impulses. This type of violence has been termed impulsive aggression.35 Acts of impulsive aggression may include physical aggression directed toward others, suicide attempts, self-mutilation, substance use, and property destruction.5 Thus, an impulsive action may entail premeditation4 if it is provoked by strong emotion. Several studies have examined the relationship between sleep and suicide (one type of impulsive aggressive behavior) in adolescence. In a community sample, 6 adolescents with less than 8 hours of sleep were more likely to attempt suicide. In addition, insomnia7 and increased rapid eye movement (REM) density8 correlate with suicidal tendencies in depressed adolescents. Other studies have found that sleep disturbances are associated with markers of poor emotional/behavioral regulation, including worse academic performance, increased problems in the classroom,9 more depressive symptoms,9,10 and substance abuse.11 To our knowledge, no study to date has examined the relationship between sleep and the larger construct of violence or impulsive aggression in adolescents. In contrast with the relatively sparse literature on sleep and aggression, the relationship between substance use and aggression has been widely studied in adolescents. Alcohol and illicit substance use are high-risk behaviors related to violence in adolescents.12,13 Also, substance use has been associated with an increased likelihood of internalizing and externalizing difficulties,14 suicide attempts,12 and expressions of anger.15 It has been suggested that emotionally dysregulated adolescents use substances to “self-medicate” mood problems.16 In addition to the relationship between substance use and emotional dysregulation, substance use has been associated with sleep disturbance;11,17 in fact, sleep disturbance in young children may be a significant risk factor for substance use in adolescence.17 This and the associations between substance use and aggression provide support for a causal model in which the relationship between sleep and high-risk behaviors may be mediated by emotional dysregulation. A large epidemiologic study of adolescents recently found that psychopathology mediated the relationship between sleep disturbance and substance use,11 thereby supporting this model. We sought to test the relationship between sleep and aggression (a marker of emotional dysregulation) by examining response to an integrative, behavioral sleep treatment for adolescents who recently completed substance-abuse treatment. We hypothesized that adolescents who reported experiencing aggressive thoughts Sleep and Aggression in Substance-Abusing Adolescents: Results From an Integrative Behavioral Sleep-Treatment Pilot Program