Inadequate sleep health (i.e., insufficient sleep quantity and quality) [1
] is becoming more prevalent among children. Children increasingly report shorter sleep duration, longer time to fall asleep, and daytime sleepiness [2
]. This may lead to lower emotion regulation [5
], a shorter attention span [5
], reduced school performance [6
], and an increased risk of overweight and diabetes later in life [5
]. This rising prevalence and its negative consequences indicate a need for effective interventions to promote healthy sleep among children.
Effective preventive healthy sleep interventions require identification of the most important and changeable determinants of inadequate sleep [13
]. A systematic review on longitudinal studies found that determinants of children’s inadequate sleep duration included inadequate past sleep health and a higher amount of screen time [14
]. Of these, screen time is the only determinant that can be changed with behavioural interventions. Another review, which also included cross-sectional studies and trial/intervention studies, found that changeable determinants of children’s healthy sleep included establishing bedtime routines, maintaining a regular sleep schedule, setting age-appropriate bedtimes, ensuring a positive atmosphere at home, falling asleep independently, and meeting children’s emotional needs during the day [15
]. In addition, a participatory mixed-method study identified the determinants of inadequate sleep perceived by children (aged 9–12 years) and parents, and these included fear, affective state, stressful situations, discomfort, physical well-being, sleep environment, energy, screen behaviour, stimulating activities, physical activity, diet, sleep schedule, family sleep habits, and social norms [16
Children and parents are important stakeholders with valuable knowledge about children’s sleep health and its determinants. Other stakeholder groups with potential valuable insights include professionals with practical and clinical experience with children’s sleep health. Such professionals can also provide estimates of the occurrence of these determinants in practice. This knowledge can inform future healthy sleep intervention development and give direction to future research on determinants of child sleep health.
Therefore, we aim to explore the perspectives of professionals with expertise in children’s sleep health on potential determinants of inadequate sleep health among children aged 4–12 years.
The aim of this study was to explore the perspectives of professionals with expertise in children’s sleep health on potential determinants of inadequate sleep among children aged 4–12 years. Professionals identified a large variety of potential determinants of children’s inadequate sleep. These determinants were clustered in five categories, i.e., psychosocial determinants, daytime and evening activities, pedagogical determinants, medical determinants, and sleep-environmental determinants. The determinants perceived as most important by all professionals were worrying, a change in daily life, using screens before bedtime, playing stimulating games before bedtime, an inadequate amount of daytime physical activity, an inconsistent sleep schedule, and the lack of a bedtime routine.
Screen use (e.g., television, tablet, phone, or computer) before bedtime was rated as the most important determinant. It is generally acknowledged that agitating screen use before bedtime disturbs children’s sleep [14
]. Underlying mechanisms may include the displacement of sleep time, light exposure, and psychological agitation due to inappropriate content [13
]. Interestingly, while the professionals in this study rated screen use as most important, children themselves rated screen behaviour as least important in an earlier study [16
]. Children’s positive experiences with screen use may explain this. Children may not be aware of the potential negative impact pre-bedtime screen use has on their sleep health. For example, a recent study by Cernikova et al. found that children reported sleep problems and tiredness after using digital media. However, they were unaware that this may have been a result of their media use [26
]. Furthermore, there are indications that many parents endorse the belief that watching television helps their child fall asleep [27
]. This parental attitude towards screen behaviour seems to be related to their children’s screen use [28
]. There is corroborating longitudinal evidence for a relationship between screen time (i.e., watching TV, using a computer or gaming) and children’s sleep health [14
]. However, the agreement between this scientific evidence and professionals’ perception may also be a result of professionals’ knowledge of this evidence. Furthermore, there is insufficient evidence on how much and what types of evening screen use are most disruptive to children’s sleep health [27
]. There is some evidence that interactive screen time (e.g., mobile phone or video games) is more agitating than passive use (e.g., watching TV) and that the nature of the content is important (i.e., violent content is more agitating) [27
]. Evidently, these are interesting topics for future research. One recent meta-analysis showed that interventions that control screen use can have a positive impact on children’s sleep [29
]. It therefore seems relevant to include limitation of screen time in future healthy sleep interventions, especially screen time before bedtime.
Another important difference between the perspectives of professionals, parents, and children is related to medical- and sleep-environmental determinants. Although several medical and sleep-environmental determinants were mentioned by professionals, they rated none as important. Compared to children and parents, professionals rated medical determinants as relatively less important [16
]. This may be because the underlying ideas were different; professionals mentioned diseases and disorders, while children and parents referred to having a cold or having pain in general. Moreover, children rated some parts of their sleep environment (e.g., comfort of their bed and the temperature in their bedroom) as one of the most important potential determinants, while professionals and parents considered children’s sleep environment less important [16
]. These findings highlight that various involved stakeholders can have a different perspective on the importance of potential determinants of children’s inadequate sleep health. Therefore, professionals working in child public health are recommended to consider children’s and parents’ perspectives in their advice and treatment regarding children’s sleep health.
Our results underpin the crucial role of parents in their children’s sleep health. Many perceived determinants identified in the categories psychosocial, sleep environment, daytime and evening activities, involve parents. For example, the perceived determinants “an upcoming stressful event” and “unprocessed thoughts or feelings” are less stressful for children when their parents help them cope with their feelings and emotions. This confirms that parenting behaviour is strongly related to children’s sleep hygiene at this age. To illustrate this, children’s screen use depends on the rules set by their parents, and children are more likely to be physically active during the day when this behaviour is encouraged by their parents [30
]. Teaching parents skills to effectively limit their child’s agitating screen use before and after bedtime and encourage physical activity during the day may contribute to positive changes in their child’s sleep health [15
]. Hence, it seems valuable for future interventions to focus on improving parenting skills in order to change children’s behaviour and, subsequently, their health [34
Many of the perceived determinants identified by professionals in this study were also identified by children and parents [16
]. As this study explored the perspectives of professionals on potential determinants, the results of this study do not provide evidence for a relationship between the identified factors and children’s sleep health. For many of the identified factors, there is at least some evidence for an association with child sleep health [14
]. However, further longitudinal research is required to examine whether the identified factors are actual determinants of children’s sleep.
From the wide range of identified potential determinants in several determinant domains, we can conclude that children’s inadequate sleep health is a multi-factorial problem. Furthermore, many of the determinants may be interrelated. Finally, every determinant has several stakeholders at different levels of the social ecological model [35
]. For example, the determinant “structural daytime and evening routines” includes parents and other family members (e.g., siblings, grandparents) as stakeholders, while the determinant “noise” includes other stakeholders such as neighbours and city planners. These stakeholders may also be interrelated. This makes children’s inadequate sleep not only a multi-factorial but also a complex problem. A complex problem can be defined as a problem that is difficult to demarcate and define, with no fixed amount of possible solutions, and where everything is interrelated and dynamic [37
]. This complexity means a single solution will be insufficient to structurally promote healthy sleep for all children, because determinants and, in effect, adequate solutions may vary widely. One way to tackle this problem could be to use “systems thinking” for the development of preventive healthy sleep interventions for children. Systems thinking means capturing the problem as a whole rather than its individual parts, while taking into account the interrelatedness between these parts and the dynamic character of the health behaviour, in this case sleep behaviour, to make sense of a complex situation [38
The identified determinants and the clustering of these determinants differed somewhat between the three groups of professionals. One reason may be that the online process included an individual brainstorm session rather than a group brainstorm, which could have yielded new ideas more easily. An idea for future online concept mapping sessions is to organise a collective online brainstorm session. The differences between the three groups of professionals may also be ascribed to the nature of their profession. Whereas the groups consisting of child public health nurses and doctors were more generally educated on children’s health and saw children with a wide variety of problems, the group of sleep experts included professionals who specialised in children’s sleep health and mostly saw children with sleep-related problems or performed research in this field. Furthermore, only the group of sleep experts identified a cluster “sleep hygiene”. This cluster contained several types of determinants, such as psychosocial, pedagogical, and sleep-environmental, of which many were similar to ideas in the cluster “daytime and evening activities” identified by the group of nurses. An explanation for this different clustering between groups may be a difference in the terminology used in different fields of expertise.
According to the professionals participating in this study, future healthy sleep interventions should at least promote a regular structure of daytime and evening routines; child-appropriate, set bedtimes; an adequate amount of relaxation before bedtime; and the avoidance of agitating activities that can increase alertness or anxiety. These determinants were identified as go-zones by all groups of professionals. The go-zones identified by doctors were mainly pedagogical-environmental determinants, while those identified by nurses were mostly psychosocial. Most of these go-zones were clustered as sleep hygiene determinants by the sleep experts. The go-zone plot of sleep experts showed more than half of the generated ideas in the “go-zone”, which means that they rated these ideas as both important and often occurring in practice. This corresponds to the occupation they perform. Little is known about the effectiveness of these appointed “go-zones”. One previous review [40
] found that denominators across effective interventions included focussing on multiple health behaviours and intervention settings and integrating multiple behaviour change strategies that target the most important determinants. There is a need for more high-quality evaluation studies on interventions that promote children’s sleep health.
The validation study confirmed the adequacy of the original clustering and importance rating. The validation sample also identified some missing determinants: negative self-image, parents’ resilience, lack of attention from parent(s), high sensitivity, no time to put child to bed, parents set the wrong example, social norm for playing outside, parents’ ability to respond to the child’s sleep problems, parents’ attitude towards sleep, and absence of stuffed toy. This may be explained by the specific expertise of the additional group of professionals in the validation study: sleep therapists specialised in children’s sleep problems. Another reason may be the lack of a group brainstorm session in the original study.
Strengths and Limitations
A strength of this study is that it provides additional insights into potential determinants of children’s inadequate sleep health, which are crucial for the development of future interventions promoting healthy sleep among children. Another strength is that the group of participants was diverse in terms of occupation and included the most prominent Dutch health professionals who deal with child sleep health. Sleep experts are often involved in research into children’s sleep, while child public health doctors and nurses are in close contact with children themselves. This provided perspectives from both research and practice. Additionally, the use of the concept mapping method allowed us to collect a broad range of unique ideas on all aspects of inadequate sleep from various perspectives. The validation of our results in the validation study among a second group of professionals further strengthens our study.
However, this study is not without limitations. Firstly, the concept mapping sessions were held online, which did not allow for a group brainstorm as part of idea generation. This may have led to potential misinterpretations of ideas that were presented to the professionals in the sorting and rating task. Secondly, this study focusses on the age range of 4 to 12 years old. Since this is a relatively wide age range, with varying behaviours, needs, and parenting strategies, not all identified determinants may be relevant for every age within this range. Lastly, the use of a focus statement requires a focus on either adequate or inadequate sleep health. This led to omitting potential determinants of adequate sleep health.