Lost in the System: Identifying Gaps in Adolescent Insomnia Care Using Nationwide Claims Data and a Healthcare...

Adolescent insomnia is common, persistent and impairing, yet little is known about how and where young people with sleep difficulties are identified and treated in regular care. Recent calls to prioritise sleep health as a public health imperative underscore the need to understand diagnostic and treatment pathways for those affected. To characterise where adolescents with sleep-related difficulties are diagnosed, describe patterns of comorbidity and examine healthcare professionals' (HCPs') diagnostic practices, treatment approaches and perceived treatment barriers, we combined nationwide statutory outpatient billing data (2018-2024) for adolescents aged 15-17 years with an online survey of HCPs across clinical disciplines in Germany. Claims data captured incident sleep-disorder diagnoses and co-occurring psychiatric conditions. The survey assessed diagnostic procedures, treatment approaches, use of clinical guidelines and perceived systemic constraints. Incident sleep-disorder diagnoses increased after 2022 and were more common in girls. Comorbid depression and ADHD were frequently coded at first diagnosis, which occurred mostly in general practice. HCPs, however, viewed paediatrics as the typical first contact and primary provider of ongoing care. Sleep-hygiene counselling was widely used, whereas cognitive-behavioural therapy for insomnia (CBT-I) was rarely delivered. Contrary to guideline recommendations, pharmacological treatments were commonly employed. Reported barriers included insufficient specialised providers, diagnostic overshadowing, long waits for CBT-I and limited consultation time. Current care structures do not reliably support timely recognition or guideline-concordant management of adolescent insomnia. Priority areas include expanding CBT-I availability, enhancing referral pathways, improving assessment practices and developing parent- and youth-focused educational resources to support earlier recognition and help-seeking.