Abstract

Background: Non-pharmacological interventions improve sleeping habits and it prevents many adverse health consequences which include altered cognitive function and child mood. Aim: This study aimed to evaluate the impact of non-pharmacological interventions on improving sleeping habits among children suffering from sleep disorders. Design: A quasi-experimental research design was used in this study. Setting: This study was conducted in Out-Patient Clinics of Psychiatric Center and Pediatric Hospital affiliated to Ain-Shams University. Sample: A purposive sample was used to conduct this study. The total number of the study sample was 75 children with a confirmed diagnosis of sleeping disorders. Tools: Three tools were used in this study for data collection, 1) A structured interview questionnaire to assess children's demographic characteristics and children's knowledge regarding non-pharmacological interventions, 2) Children’s sleeping habits questionnaire (CSHQ) and 3) An observational checklist (pre/post-tests) to evaluate practices of non-pharmacological interventions. Results: There was a lack of children’s knowledge about non-pharmacological intervention, the mean±SD of 5.6±1.2, which increased in post - intervention with a statistically significant difference (P=<0.001). Moreover, there was a lack of children’s practice toward non-pharmacological intervention, with mean±SD of 4.78±3.69 which increased in post -intervention. And children reported improved sleep habits (Children’s Sleeping Habits Questionnaire: 16.27 ± 4.987 versus 11.88 ± 4.420 p=0.018. Conclusion: The current study concluded that the non-pharmacological interventions (sleep restriction, stimulus control, cognitive therapy, sleep hygiene, and relaxation training) had an evident effect on improving sleeping habits and their reported practices among Children Suffering from Sleeping Disorders. Recommendations: The study recommended that non-formal classes should be to teach children, parents, and teachers about improving sleeping habits through optimal use of the non-pharmacological intervention.

1. Introduction

Sleeping is the natural periodic of consciousness during which a status of the body and the mind typically recurs for several hours every night, in which the nervous system is inactive, the eyes are closed, the postural muscles relaxed ¹. Therefore, it's vital for children's growth, learning, memory, and homeostasis. When compromised there can be multiple physical, psychological and, behavioral complications with major ramifications on family life ².

Adequate sleep is an important factor in children's life. During sleep, the body and the brain actively work to support healthy brain and body function, improve memory, enhance learning and problem-solving skills, keep attention, controlling the emotions and behavior, coping with changes, make decisions and be creative. So, sleeping is necessary for human survival and sleep problems can have an impact on children's daytime functioning, and they are not uncommon ^{3, 4}.

Community studies discovered that sleep disorders have a high prevalence throughout childhood and adolescence, with 25% to 50% of preschool and up to 40% of adolescents experiencing sleep-related problems ⁵. On the same line ⁶, added that approximately 30% to 40% of all children were ranging from short-term difficulties in falling asleep and night waking to more serious primary sleep disorders. However, sleep problems are even more prevalent in children and adolescents with chronic medical.

Sleep quality includes a number of factors related to the ability to fall asleep and stay asleep and extends to disordered patterns of sleep, such as interrupted sleep include stress, and many health problems, especially those that cause chronic pain, strain, and another discomfort. External factors, such as what we eat and drink, the medications we take, and the environment in which we sleep can also greatly affect the quantity and quality of sleep ⁷.

Non-pharmacological interventions are noninvasive modalities and effective use for a long period without Side effects for children experiencing sleep disorders. Several studies of non-pharmacological intervention reported improving the quality of sleep. These interventions include sleep restriction, stimulus control, cognitive therapy, sleep hygiene education, and relaxation training. Thus further development and evaluation of feasible, scalable interventions integrating various factors impacting sleep quality and successful management of sleeping issues is necessary to improve the quality of life of both children and their families ^{7, 8}.

The aim of different methods of Non-Pharmacological intervention as stimulus control is to help the person rapid sleep with the bed and bedroom through decrease activities that obstacles with sleep. The aim of sleep restriction is to decrease the time spent in bed to the actual time sleeping and to increase sleep time, so as to increase sleep efficiency. The aim of cognitive therapy is to change person identify, and change dysfunctional value and attitudes about sleep and to replace them with more adaptive substitutes ^{9, 10}. Relaxation therapy such as deep-breathing exercises, Progressive muscle relaxation, Yoga and abdominal breathing, and Repetitive muscle activity use to improve their sleep and Sleep hygiene education attempts to change a person’s lifestyles and environment to improve sleep quality ¹¹.

Consequently, non-pharmacological interventions are proven, inexpensive and to promote sleeping disorders in children and the nurse has a vital role to help children and their families, in coping with sleeping disorders through identifying sleep problems, giving education about non-pharmacological interventions and refer them for follow up ¹².

Sleeping disorders are commonly occurring in childhood and can have significant effects on the health and wellbeing of both children and their families ⁴. In Egypt, the prevalence of sleeping disorders in children is 48.7%, between 6-12 years, and the majority of the 84% were males ¹³. Also, the vast majority of sleep disturbances in children are successfully managed with non-pharmacological interventions. Several studies reported that cognitive-behavioral interventions were effective. More than 80 percent of treated children demonstrated clinically significant improvements than that was maintained at short (<6 months), intermediate (6 to 12 months), and long-range follow-up (>12 months) ¹⁴. So, it is very important to examine and apply non-pharmacological interventions to improve sleeping habits among children suffering from sleeping disorders.

This study aimed to evaluate the impact of non-Pharmacological interventions on improving sleeping habits among children suffering from sleep disorders through:

1. Assess children’s knowledge and their reported practices regarding non-pharmacological interventions for sleeping disorders.

2. Design and implement non-pharmacological interventions based on an assessment of children's needs.

3. Evaluate the effect of non-pharmacological interventions on children’s knowledge and their reported practices regarding sleeping disorders.

Applying non-pharmacological interventions for children suffering from sleep disorders will improve their knowledge, practices, and sleeping habits after interventions than before.

2. Subjects and Methods

Non-pharmacologic interventions: Evidence on intervention effectiveness is particularly limited for some of these approaches include sleep restriction, stimulus control, cognitive therapy, sleep hygiene, and relaxation training and it measured by An observational checklist was adopted from Maness and Khan ¹⁵.

Sleep quality is one's satisfaction of with the sleep experience, integrating aspects of sleep initiation, sleep maintenance, sleep quantity, and refreshment upon awakening and it measured by Children’s Sleeping Habits Questionnaire (CSHQ) (pre-posttest format) developed by Owens et al., ¹⁶.

A quasi-experimental research design (one group pre/posttest) was utilized to achieve the aim of the study.

The current study was carried out at Psychiatric Out-Patient Clinics of Pediatric Hospitals and Out-Patient Clinics of Psychiatric Center affiliated to Ain-Shams University Hospitals. These settings are selected due to the high frequency of children suffered from sleeping disorders who visit these settings because these settings serve the biggest governorate.

A purposive sample consisted of (75) child with a confirmed diagnosis of sleeping disorders was used in this study. All children with sleeping disorders registered at the initiation of the study as well as those of new cases during the entire period of the study (9 months period) were invited to participate in the study from previously mentioned settings regardless of their age and gender.

The inclusion in the study sample whenever they met the following criteria.

Children’s age ranged from 6 to more than 12 years from both genders.

Children suffering from any other disorders in addition to sleeping disorders such as (ADHD, mental retardation, epilepsy, psychosis, etc…….)

Three tools were used in this study to collect the data, the first tool developed by the researchers after reviewing the national and international related literature.

The tool I: A structured interview questionnaire (pre/posttest) was developed in a simple clear Arabic language by the researchers based on a literature review ¹³ and experts' opinions in light of relevant references to assess children’s knowledge regarding non - pharmacological interventions. It consisted of two parts:

Part I: It was included data about:

1. Demographic characteristics of children suffering from sleeping disorders such as age, gender, rank, level of education, residence, past history for a child with sleeping disorders, and family history.

2. Children’s knowledge (pre-posttest format) regarding applying non-pharmacological interventions which consisted of 10 closed-ended questions such as stimulus control, sleeping hygiene, relaxation training, cognitive therapy, and sleeping restrictions.

Scoring system

For knowledge, a correct answer was scored as one and an incorrect answer as zero. The scores were summed up and converted into a percentage score from 0 to < 50 referred to poor knowledge, 50 < 75 referred to average knowledge while the score from 75 ≤ 100 referred to good knowledge.

Tool II: Children’s Sleeping Habits Questionnaire (CSHQ) (pre-posttest format) developed by Owens et al., (2000) which consisted of (33 items) to examine eight sleep domains. It includes parasomnia, bedtime resistance, sleep duration, sleep onset delay, night waking, sleeps anxiety, daytime sleepiness, and sleep disorders breathing.

Scoring system

The Children’s Sleeping Habits Questionnaire (CSHQs), is a children-rated questionnaire comprised of 45 items; 33 scored questions, and each scored question is rated on a 3-point scale as occurring “usually” (i.e., 5-7 times within the past week), “sometimes” (i.e., 2-4 times within the past week), or “rarely” (i.e., never or 1 time within the past week). A number of items on the questionnaire are reverse-scored so that higher scores consistently indicated problem behaviors. Ratings are combined to form eight subscales: bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night waking, parasomnias, and sleep-disordered breathing, and daytime sleepiness.

A total sleep disturbance score is calculated as the sum of all CSHQs scored questions and can ranged from 33 to 99. The minimum total score is 33 and the maximum is 99. The children total score were classified as follows: poor habits sleep scale score was less than 50% represent >50 marks, average habits sleep scale score was represented 50% and more than which present < 50 marks.

Tool III: An observational checklist: It was adopted from Maness and Khan ¹⁵. It filled by the researchers to evaluate studied children’s practices in relation to relaxation techniques (Deep-breathing exercises, imagery exercises, progressive muscle relaxation, yoga and abdominal breathing, and repetitive focus).

Scoring system:

A correct practice had (1) score, while the incorrect had (zero). It was scored into either inadequately done (less than 60%) or adequately done (60% and more). The total score was categorized as satisfactory = 70 - 100, or unsatisfactory = less than 70.

Content validity was performed by six colleges; two professors from the Pediatric Nursing Department, two professors from the Community Nursing Department, and two professors from the Psychiatric Nursing Department of Nursing Faculty. All experts were affiliated to Fayoum University, Egypt. The developed tools were tested for reliability. The reliability test of the translated version was established by using Cronbach's alpha and Pearson correlation which showed good internal consistency construct validity, Cronbach's Alpha coefficient test = (0.887) for quality of sleep tool, and (0.865) for Non-pharmacological intervention tool and An observational checklist was (0.854).

Procedure:

The study was conducted in three phases (preparatory phase, implementation phase, and evaluation phase).

(1) The preparatory phase; a) Preparation of the content:

The researcher checked on the related materials and literature broadly. Assessments of the children’s knowledge and practice were done by the researchers. Non -Pharmacological Interventions were developed according to needs, requirements, and deficiencies that were translated to the aims and objectives of the intervention. The application of non- pharmacological interventions, done by the researchers, lasted for 9 months from the beginning of March 2018 to the end of November 2018. The researchers visited the study settings two days per week; Sunday in Psychiatric Outpatient Center and Monday in the psychiatric Outpatient Clinic of Pediatric Hospital affiliated to Ain-Shams University Hospitals at Morning shift from 9.00 a.m. to 2.00 p.m. The questionnaire took about 25 minutes, and 15 minutes for the checklist to be filled by the researchers.

The planning phase includes the program strategy (time table, teaching methods, and materials used). The content of the program includes an introduction of basic knowledge related non -pharmacological intervention as (Techniques for the following; sleep restriction, stimulus control, cognitive therapy, sleep hygiene and relaxation training) The researchers used discussion, role-play, feedback and presentation to help children using effective non- pharmacological intervention.

b) Assessment and data collection: (pretest) All children completed all pre-study items before the beginning of the program. This assessment was completed through children's self-report.

(2) The implementation phase: By developing the non - pharmacological intervention content and implementing it.

- The general objective of non - pharmacological intervention was to improve the children’s knowledge and practice regarding apply Techniques of non-pharmacological interventions for improving sleeping habits, and specific objective to help children applying different Techniques of non-pharmacological interventions which lead to improving sleep habits;

1- Improving sleep habits by using sleep restriction

2- Improving sleep habits by using stimulus control

3- Improving sleep habits by using cognitive therapy

4- Improving sleep habits by using sleep hygiene

5- Improving sleep habits by using relaxation training

- The tools were filled through interviewing. The purpose of the study was explained to the children. The study was carried out in the morning in the outpatient clinic. And the children divided according to their age, the age of the first group start from 6 - 12 years (68 children) at elementary school, and children divided into subgroups each group consisted of 3-4 child and the second age group >12 years at preparatory school ( 7 children). At the initial interview, the researcher introduces herself to initiate a line of communication, explain the purpose of Non- pharmacological intervention, based on the result of the pre-test questionnaire, the researchers utilized multiple sessions (theory & practice) ranged from 3-5 sessions and each session needed from 1-2 hours, and meeting with subjects was two days per week. And fill out the structured interview questionnaire (tool one) to assess children’ knowledge before the implementation of intervention about the following The first part: Theoretical part: It included data related to;

- 1) Assess sleep restriction knowledge of non- pharmacological intervention as Limit time in bed to the number of hours actually spent sleeping (not less than five hours).

- 2) Assess Stimulus control knowledge of non- pharmacological intervention as Lie down to sleep only when feeling sleepy, Sleep only in the bedroom, using the bed and bedroom only for sleep, Avoid wakeful activities or any behavior in the bed, Leave the bedroom when awake for approximately 15-20 minutes or when you begin to feel frustrated, Maintain a consistent sleep-wake cycle by setting the alarm for the same time each morning and Do not nap during the day.

- 3) Assess cognitive therapy knowledge of non- pharmacological intervention as identifying negative thoughts, increasing positive thinking and use of handout to write down thoughts, or keeping a worry journal at bedtime.

- 4) Assess sleep hygiene education knowledge of non- pharmacological intervention as Avoiding vigorous exercise close to bedtime, avoid empty stomach or heavy meals before bedtime, avoid the use of alcohol and other addicting substances, avoid caffeine, especially within a few hours before sleep, avoiding smoking close to bedtime, avoid keeping a clock close to the bed, avoid excessive wakeful time in bed (>20 minutes), controlled bedroom environment quiet, dark and temperature and obtain morning light exposure used therapeutically. The second part: Practical part: It included data

- 5) Assess relaxation training of non- pharmacological intervention covers the following items (Deep-breathing exercises, imagery exercises, progressive muscle relaxation, yoga, and abdominal breathing and foot bath ) and fill out the observational checklist as (Beginning with the muscles exercise in the face, squeeze (contract) muscles gently massage with lavender oil for one to two seconds and then relax. Repeat about five times. Use the same technique for other muscle groups, usually in the following sequence: jaw and neck, shoulders, upper arms, lower arms, fingers, chest, abdomen, buttocks, thighs, calves, and feet. Repeat this cycle for 45 minutes, foot bath, and deep breathing exercise. The practical part was conducted through demonstration, re- demonstration, and video. It was taken in 2 sessions (each session for one hour) and covers the following items (Relaxation training, foot bath, deep breathing exercise).

- (3): Evaluate the effect of non- pharmacological interventions on the studied children using the pre - constructed tools as follows: Posttest was done within two weeks when the children came to the outpatients clinics.

Pilot study: A pilot study was conducted before starting data collection on 8 children, chosen randomly from the previously mentioned settings. It was done to estimates the time required for filling in the tools and checking the clarity, applicability, and relevance of the questions. Based on the results of the pilot study, the necessary modifications were done; those children were excluded from the main study sample.

The necessary approval from the administrative authority of Ain-Shams University Hospitals was taken after issuing an official letter from the Dean of Faculty of Nursing, Fayoum University. An informed consent written and verbal to participate in the current study was taken after the purpose of the study was clearly explained to each child. Confidentiality of obtained personal data, as well as the respect of participant’s privacy, was totally ensured. A summary of the interventions was explained to every child who voluntarily agreed to participate in the study and they were informed that they can withdraw from the study at any time without giving any reason.

Data collected from the studied sample were revised, coded and entered using PC. Computerized data entry and statistical analysis were fulfilled using the Statistical Package for Social Sciences (SPSS), version 20. Data were presented using descriptive statistics in the form of frequencies and percentages. Chi-square test (X₂) was used for comparisons between qualitative variables. MackNemar test and paired-t test were also used. Statistical significance was considered at p-value <0.05.

3. Results

Table 1 clarified that the mean and SD of studied children's age were 7.3 ± 2.4 years and the majority (80%) of them were males and 40% were first ranked. Also, the majority (86.7%) of studied children were in primary school. As regards, family history of sleeping disorders, it was found that most of the studied sample had a negative history in both father's and mothers' families (92%, 89.3%) respectively.

Table 2: Clarified that the majority (86.7%) of studied children had poor knowledge regarding cognitive-behavioral therapy pre-interventions, while slightly less than three-quarters of them (72.7%) had good knowledge post interventions. Regarding sleeping control, it was found that slightly more than three quarters (76%) of children had poor knowledge pre-interventions, while slightly more than four-fifths (82.7%) had good knowledge post interventions. Also, it is clear from this table that, statistically significant differences between the studied children's knowledge pre/post interventions, whereas the mean of studied children's knowledge in the posttest, was lower than pretest (8. 5±1. 4 & 5.6±1.2 respectively).

Table 3: Revealed that, more than two thirds (69.3%) of the studied children after settling down, usually takes a time to fall asleep pre-interventions, compared to minority (10.7%) post interventions. While, slightly less than three fourths (74.7%) of them sleep too little pre-interventions, compared to the minority (18.7%) post interventions. A statistically significant difference between the studied children's sleeping habits pre/post guidelines (t= 2.419, p < 0.018).

Table 4: Revealed that more than half (52%) of the studied children rarely using the bed and bedroom only for sleep pre interventions compared to the minority (9.3%) of them post interventions. While nearly three quarter (70.7%) of them rarely positive thinking and replace dysfunctional beliefs regarding sleep in cognitive therapy pre interventions compared to more than half (56%) of them post interventions. A statistically significant difference between the studied children's stimulus control and cognitive therapy pre/post interventions (p <0.001).

Table 5: Revealed that as regards sleep hygiene, less than two thirds (61.3%) of studied children avoid empty stomach or heavy meals before bedtime pre interventions compared to the minority (10.7%) of them post interventions, with statistically significant differences between the two phases regarding all sleep hygiene items and sleep restrictions pre/post interventions (p <0.001).

Table 6: Revealed that there was an improvement in children’s practices score regarding deep-breathing exercises, imagery exercises, progressive muscle relaxation, yoga, and abdominal breathing, and foot bath in post interventions, with a statistically significant difference of PSQI total score after applying non-pharmacological intervention, P=< 0.001.

Table 7: Revealed that, there were no statistically significant differences between total sleep habits of studied children and their demographic characteristics (age, gender, child rank, education, and residence).

4. Discussion

Sufficient sleep for children is essential to ensure a transition into healthy adulthood. However, sleeping disorders continues to increase worldwide. So, it is necessary to make sleep a high-priority and take action to improve sleep among children ¹⁷, The present study aimed to assess the effect of non-pharmacological interventions on children suffering from sleep disorders.

The results of this study showed that most of the studied children's age ranged between 6-<12 years. Most studied children were males and at primary school. This finding was in agreement with the study of Hawkins &Takeuchi, ¹⁸, in the USA, who studied social determinants of inadequate sleep in US children and adolescents, and reported that inadequate sleep increased to (36%) among 6-9 years old and (41%) among 10-13 years old children.

As regards total children's knowledge about non-pharmacological interventions, the current study clarified that there were highly statistically significant differences between children's knowledge pre and post-intervention (P < 0.001). This may be due to that children might have ignored knowledge about non-pharmacological interventions. This finding was in agreement with Kudchadkar ¹⁹, who study the sleep of critically ill children in the pediatric intensive care units they found that environmental interventions, such as noise reduction and lighting optimization and provide safe and effective strategies to promote sleep. Also, this finding supported by Wieczorek ²⁰, who study the impact of quality improvement interventions to promote early mobilization in critically ill children they found that, cognitive-behavioral interventions, physical therapy, and exercises provide modes of relaxation to decrease stress and anxiety during the day to promote rest at night. This study showed an unsatisfactory level of children’s knowledge before implementing non-pharmacological interventions. From the researchers’ point of view, there are easy for children to implement non-pharmacological interventions through the modified environment is reducing stimulus such as (light, loud voice, etc), promote exercise, hygienic sleep, and cognitive behavioral therapy.

Concerning child habits during sleep pre and post interventions, it was found that most of them are sleeping during watching TV. This study was supported by Fuller et al., ²¹, in Pennsylvania State, who studied bedtime use of technology and associated sleep problems in children, and reported that there was a significant relationship between average hours of sleep and using any technology devices before bedtime, children who watched television at bedtime reducing sleep quantity and quality than those who didn't watch television at bedtime.

As regards total child habits, there were statistically significant differences between pre and post interventions of studied children. This study was in accordance with, El-Bahy ²², who mentioned that there were highly statistically significant differences between sleeping disorders in children and the controls group regarding; child falls asleep time, sleep duration (p<0.01) after applying non-pharmacological interventions. On the other hand, Abd El Hameed ²³, reported that there were statistically significant differences between non-pharmacological interventions and sleeping disorders of studied children regarding; child wets the bed at night, snores loudly and child walked during the night. Also, this result supported by the study of Stanford Health Care ²⁴, about pediatric sleep disorders who documented that, poor sleep quality and/or quantity in children are associated with a lot of problems, including disruptive behaviors during sleep such as sleepwalking or other parasomnias symptoms. From the researchers’ point of view, the highly statistically significant differences between pre and post interventions are related to that, applying non-pharmacological interventions improves a child's habits.

Regarding children’s practice scores of non-pharmacological interventions, there was a significant improvement in practices' scores of the studied children in post interventions. These results may clarify that the preparation of interventions was successful in achieving better information and practices' levels between children. This study was supported by Wilfred et al., ²⁵, who studied current pharmacological and non-pharmacological options for management of insomnia, confirmed that, a participant receives stimulus control saw a significant increase in total sleep time and mean reduction in sleep latency, time awake after sleep onset and number of night waking. On the other hand, Zhong et al., ²⁶, who studied the efficiency of cognitive behavior therapy in children and adolescents with insomnia, observed that there were statistically significant differences in sleep onset latency and sleep efficiency and no significant relations were found for the wake after sleep onset or total sleep time.

In relation to applying sleep hygiene on studied children pre/post program interventions. The result of this study indicated that a statistically significant difference was observed. This study was supported by Eduard et al., ²⁷, who studied psychometric properties and clinical relevance of adolescent sleep hygiene scale in Dutch adolescents, confirmed that sleep quality, sleep duration, chronic sleep reduction, and the score of an adolescent with insomnia improved after applying the non-pharmacological treatment. This study was in accordance with Dewald and Oort ²⁸, who studied the effect of sleep extension and sleep hygiene advice on sleep and depressive symptoms in an adolescent: A randomized control trial reported that, during the third week of the experimental, adolescent in the sleep extension group had earlier bedtimes, earlier in sleep onset, spent more time in bed, chronic sleep reduction, insomnia symptoms and depressive symptoms diminished significantly and slept longer than adolescent in the control group. From the researchers’ point of view, these results confirmed that the children’s habits improved post-program interventions than before. Concerning relaxation training regarding non-pharmacological practices pre and post interventions, it was found that a statistically significant difference was observed. This study was supported by Umesh, ²⁹, who studied non-pharmacological management of insomnia, reported that, relaxation training is considered the most effective therapy in the treatment of chronic insomnia which reduces somatic tension and intrusive thoughts at bedtime. From the researchers' point of view, this result supported the research hypothesis.

The present study finding clarified that there were no statistically significant differences between total sleep habits of studied children and their demographic characteristics (age, gender, child rank, education, and residence). This result was contrary to Abd El-Hammed ²³, who reported that there were statistically significant differences between total sleep disorders (the children's sleep habits checklist) and child's age, gender, child rank, and education. From the researchers’ point of view, this result is related to that, children's age was 7.3± 2.4 years, this age needed more time and effort to improve the quality of sleep.

5. Conclusion

Based on the results of the current study the following can be concluded: Applying non-pharmacological interventions treatment should be the first intervention had an evident effect on improving children’s knowledge, practices, and sleeping habits after interventions than before.

6. Recommendations

Based on the findings of the current study, the following recommendations are suggested:

- The educational and training program is essential to increase children’s’ awareness of applying non-pharmacological interventions.

- Children with sleeping disorders should be start treated early by non-pharmacological intervention to improve their behavioral symptoms immediately after confirmed diagnosis.

- Orientation programs on large mass media as TV should be carried out, in order to increase public health awareness about sleep disorders in children.

References