Abstract
Background:
Adolescents’ sleep problems are commonly assessed by parents’ interview.
Aim:
To translate self-reported Children’s Report of Sleep Patterns (CRSP) questionnaire in Hindi language (CRSP-H) and assess sleep pattern of adolescents.
Methods:
CRSP questionnaire was translated in Hindi language following standard guideline. Translated CRSP-H was used for adolescents (11–18 years) of 7th–12th grade to assess their sleep pattern in term of sleep duration, Sleep Hygiene Indices (Caffeine Index, Activities Hour Before Bed index, Sleep Location Index, and Electronics Use at Sleep Onset Index), Sleep Disturbance Scores (Bedtime Fear/Worries Scale, Restless Legs Scale, Parasomnias Scale, and Insomnia Scale), and Sleep Patterns.
Results:
Participants included 231 children (boys 55%; age 14.1 ± 1.6 years; class VII/VIII/IX/X/XI/XII 17.8%, 20.8%, 29.4%, 13.4%, 13.8%, and 4.8%, respectively; time taken 20.8 ± 7.2 min). Sleep duration on weekdays and weekends were 7.4 ± 1.2 and 9.0 ± 1.5 hours, respectively. 138 (67.6%) participants were good sleepers. Sleep Disturbance Scores were worse in poor sleepers. Senior grade students had shorter sleep on weekdays (P = 0.04) and weekends (P = 0.04). Bedtime for 57.1% was between 9 and 11 pm on weekdays and 61% after 11 pm on weekends. Poor sleepers had higher (P < 0.01) Electronic Use at Sleep Onset, Bedtime Fears, Restless Leg Syndrome Symptoms, and Insomnia in comparison to good sleepers. Poor sleepers had significantly higher (P < 0.01) sleepiness and bed wetting scores (P = 0.02).
Conclusion:
Adolescents sleep for 7.4 hours on weekdays and 9 hours on weekends respectively. Higher classes and higher Sleep Disturbance Scores are associated with reduced sleep duration.
Keywords: Insomnia, parasomnia, sleep disturbance, sleep duration, sleep score
INTRODUCTION
Sleep is a complex process and is essential for physical strength, physiological growth, and psychological development. Sleep pattern shows gradual transition from a biphasic, day time nap and overnight sleep in preschool children to a monophasic overnight sleep in adolescence.[1] Newborns need maximum sleep duration that gradually reduces through adolescence.[2,3] Sleep quality and duration have widespread impact on cognitive function, scholastic performance, homeostasis and metabolism, sexual growth, development, obesity, diabetes, psychological health, and cardiovascular health of a child.[4] Insufficient or poor-quality sleep results in excessive daytime sleepiness, impaired attention span, poor scholastic performance, poor learning,[5] difficulty in emotional regulation,[6] obesity,[7] and psychological illness.[8] It is important to recognize the problem of poor or insufficient sleep in a child. Parents are less aware about the child’s sleep and sleep quality[9] as children get older.
Sleep disturbances are common in among all the groups in community. Over 37% of elderly have sleep problems,[10] 22% of general population have insomnia globally,[11] 10%–38% of children in Asian countries are reported to have sleep problem[12]; further, sleep problems among the adolescents are reported to be gradually increasing over the years.[13] In India, both rural and urban adults, have been shown to have high prevalence of sleep related disorders.[14,15]
India data on prevalence of sleep disorders are limited to pre-school and school going children because authors could collect information about the sleep problem from their parents by using Children Sleep Habits Questionnaire. It seems inappropriate and scientifically inaccurate to collect such information from the parents of an adolescents. In lack of a self-reporting questionnaire in Hindi language, Indian data on sleep pattern and disturbance among adolescents are extremely limited.
The Children’s Report of Sleep Patterns (CRSP), a self-reported English language questionnaire of sleep, is validated for ages 8–12 years[16] and adolescents.[17] Till date, CRSP questionnaires has not been translated or validated in any other language, including Hindi language.
Akin to pre-school and school-going children, adolescents are also likely to suffer from sleep disturbances. This study was conducted to translate CRSP questionnaire in Hindi language (CRSP-H) and use the translated version to study the sleep pattern among adolescents in an urban setting in India.
METHODS
This cross-sectional study was conducted between July 2016 and June 2019 in the Department of Pediatrics, Era’s Lucknow Medical College, Lucknow, India. A large proportion of time was used in translation of original English language CRSP into Hindi language, followed by its pre-testing. Hence, we conducted this study in two parts, first we translated the CRSP-H followed by sleep assessment of adolescents using CRSP-H.
Children’s report of sleep patterns questionnaire
The questionnaire measures different components of sleep among children. It is available in two formats, namely self-administered version, and parent-proxy version. The instrument has a set of 62 questions to gather information about the demography, sleep patterns (sleep continuity last night, typical weekday sleep, typical weekend sleep), Sleep Hygiene Indices, Sleep Disturbance Scales, and Sleepiness of a child. It also has a few indicator items.[16,17] The response to each of the questions is scored as per the recommended instruction. The responses to the questions, used for the synthesis of various indices, are recorded on a Likert scale of 1–3 or 1–5. Lower score represents the favorable sleep index or less sleep disturbances.
Translation of children’s report of sleep patterns questionnaire
Translation of CRSP questionnaire and pre-testing of developed Hindi version was done between July 2016 and July 2017. The CRSP questionnaire was translated into Hindi language following published standards.[18] Four independent, bilingual linguistic experts, not related to this study, were selected. The process of translation was completed in the following steps. First, two experts independently completed forward translation from English to Hindi and developed versions 1A and 1B, respectively. Second, both the forward translators and the subject experts had a discussion on each item to reach version 2. Third, the version 2 was independently back translated, from Hindi to English, by another set of two language experts to develop versions 3A and 3B, respectively. Fourth, following item-wise discussion among the two back translators and the subject expert, a version 4 was reached. Fifth, the version 4 was compared with the original English version to identify the differences and make appropriate amendments in version 2. After many rounds of iterations, version 5 in Hindi language was developed. During the entire process of translation, primacy was given to conceptual equivalence of the item translated. This version 5 was pre-tested in ten adolescents by a detailed personal interview and children were encouraged to report the difficulties faced in understanding or responding to the items. Children included in pre-testing were not included in the main study. Whenever children reported difficulties, the issue was discussed in detail and appropriate changes were made in version 5 to reach the final version 6 in Hindi language that was called CRSP-H [Supplementary File 1 (2.6MB, pdf) ].
Participants
A cross-sectional study was conducted in two schools in the vicinity of our institute, selected because of convenience and our prior association with their management. School administration/principals and class teachers were provided information about the study plan and its importance and their consent was secured prior to recruitment of study participants. School visits were completed between August 2017 and October 2017.
No specific sampling strategy was adopted for the selection of study participants. All the students 11–18 years of age, who were studying in 7th–12th grade, were invited to participate. Children with either acute illness in last 4 weeks or those with uncontrolled or advanced chronic illness, as judged with history, were excluded. If the parents had given implied consent for the participation of their wards, a written informed ascent was secured from the students to participate. They were provided with CRSP-H and were requested to complete it. The questionnaire was primarily self-administered but the investigators helped the participants, if required. For data analysis, the children were grouped as junior grade (class 7th and 8th) and senior grade (class 9th–12th). Children with total daily sleep duration <9 hours or ≥9 hours were called good sleepers or poor sleepers. This cut-off for sleep duration of 9 hours was chosen as the mean of the recommended 8–10 hours daily sleep duration for adolescents.[3]
Statistical analysis
Assuming 30% school going children will be poor sleepers, 80% power, and 5% level of significance, 20% precision, design effect of 1.5, we estimated a sample size of 228. Categorical and numerical data are expressed as proportion and mean ± standard deviation (SD), respectively. Groups are compared using Chi2 and t-tests or one-way analysis of variance (ANOVA) tests, respectively. Psychometric properties of the CRSP-H were assessed with Spearman correlation coefficient between the various domains and Cronbach’s alpha to examine the internal consistency of each domain. Data were analyzed using SPSS 23 software (StataCorp. 2019. Stata Statistical Software: Release 16, College Station, TX: StataCorp LLC).
Study was approved from the Institutes Ethics Committee (ELMC/R_Cell/EC/2016/188) and the subjects were recruited after obtaining consent from school authorities and written informed assent of participant. In view of less than minimal risk involved in our study, written permission of the parents was not obtained. Though a written information sheet was sent to them, through their ward by the school administration, a few days before the school visit, seeking their implied consent for inclusion of their ward in our study. Ethics approval was secured after obtaining permission from the original developer of the CRSP questionnaire to translate it into Hindi language.
RESULTS
Participants
Of the 310 children invited for participation, parents of 250 agreed to participate (80.6%) and their data were collected. Nineteen of the 250 children were excluded because of missing information and remaining 231 (boys 55%; age 14.1 ± 1.6 years; in class VII/VIII/IX/X/XI/XII were 17.8%, 20.8%, 29.4%, 13.4%, 13.8%, and 4.8%, respectively) were included for analysis. They took an average of 20.8 ± 7.2 min to complete the CRSP-H.
Psychometric properties of the children’s report of sleep patterns in Hindi
The correlation coefficients between the various sleep hygiene indices, sleep disturbance indices, and sleepiness scales are summarized in Table 1. Overall, the correlation coefficients between the domains were poor. The maximum achieved coefficient was 0.552. The Cronbach alpha is also shown in Table 1. All the Cronbach alpha is below 0.70.
Table 1.
Cronbach alpha and Spearman’s correlation coefficients of various domains of sleep questionnaire
| Caffeine Index | Activities Hour Before Bed Index | Sleep Location Index | Electronics Use at Sleep Onset Index | Bedtime Fear/Worries scale | Restless Legs scale | Parasomnias scale | Insomnia scale | Sleepiness scale | |
|---|---|---|---|---|---|---|---|---|---|
| Cronbach alpha | 0.175 | 0.472 | 0.515 | 0.456 | 0.413 | 0.652 | 0.533 | 0.659 | 0.551 |
|
Correlation coefficients | |||||||||
| Caffeine Index | 1.000 | ||||||||
| Activities Hour Before Bed Index | 0.262 | 1.000 | |||||||
| Sleep Location Index | 0.456 | 0.367 | 1.000 | ||||||
| Electronics Use at Sleep Onset Index | 0.219 | 0.338 | 0.342 | 1.000 | |||||
| Bedtime Fear/Worries scale | 0.185 | 0.09 | 0.453 | 0.172 | 1.000 | ||||
| Restless Legs scale | 0.190 | 0.197 | 0.332 | 0.257 | 0.439 | 1.000 | |||
| Parasomnias scale | 0.051 | 0.123 | 0.234 | 0.141 | 0.202 | 0.274 | 1.000 | ||
| Insomnia scale | 0.154 | 0.238 | 0.187 | 0.182 | 0.552 | 0.394 | 0.210 | 1.000 | |
| Sleepiness scale | 0.151 | 0.142 | 0.345 | 0.143 | 0.305 | 0.416 | 0.157 | 0.355 | 1.000 |
Sleep duration
The mean sleep duration, in the overall group, during the weekdays and weekends were 7.4 ± 1.2 and 9.0 ± 1.5 hours, respectively. During weekdays, boys were sleeping 0.4 hours less than girls (7.2 ± 1.1 versus 7.6 ± 1.3 hours; P = 0.01). The sleep durations were comparable at weekends (8.9 ± 1.6 versus 9.1 ± 1.4; P = 0.23). With increasing grades of study, the sleep duration significantly reduced during the weekdays (P = 0.03) but not during the week ends (P = 0.123). Their sleep duration ranged 6.8–7.7 hours in weekdays and 8.3–9.3 hours in weekends. As compared to junior grades, senior grades students were sleeping for significantly shorter duration during the entire week, including weekdays (P = 0.04) and weekends (P = 0.04). The sleep duration in senior grade student was shorter by 0.3 hours in weekdays and 0.4 hours in weekends. Overall, 138 (67.6%) participants were good sleepers. The proportion of good sleepers in junior grades (74.3%) and senior grades (64.2%) were not different (P = 0.14). [Table 2]
Table 2.
Sleep duration among children studying in different grades
| Grade of study | No (%) of children (n=229) | Sleep duration in week days | P | No (%) of children (n=230) | Sleep duration in week ends | P |
|---|---|---|---|---|---|---|
| Grade 7 | 41 | 7.7±1.1 | 0.03 | 41 | 9.3±1.5 | 0.12 |
| Grade 8 | 48 | 7.5±1.3 | 48 | 9.2±1.5 | ||
| Grade 9 | 66 | 7.5±1.2 | 67 | 9.1±1.4 | ||
| Grade 10 | 31 | 6.9±1.2 | 31 | 8.6±1.7 | ||
| Grade 11 | 32 | 7.3±1.2 | 32 | 8.7±1.4 | ||
| Grade 12 | 11 | 6.8±0.9 | 11 | 8.3±1.2 | ||
| Junior grade (7th–8th) | 89 | 7.6±1.2 | 0.04 | 89 | 9.2±1.5 | 0.04 |
| Senior grade (9th–12th) | 140 | 7.3±1.2 | 141 | 8.8±1.5 |
Data are expressed as mean±SD; Data are compared using ANOVA and t-tests. SD: standard deviation, ANOVA: analysis of variance
Sleep patterns
The responses given to the sleep pattern related questions are summarized in Supplementary File 2. On asking about the last night sleep, only 3.2% slept before 9 pm, 2.6% took medication to help them to sleep, 31.2% woke up at night after sleep, 45.5% woke up before 6 am, and 80.5% felt that they had a great or good sleep at night. On typical school going weekdays, 30.3% children get up at or before 6 am, only 2.6% go to bed before 9 pm, but 57.1% go to bed by 11 pm. On a typical weekend, 61% go to bed after 11 pm, and 55% wake up after 8 am. After sleep onset, 36.8% children do not wake up in night. Only 11.7% participating were regularly taking a nap in daytime and 67.6% adolescent were satisfied with their sleep and self-rated a great/good sleeper.
Supplementary File 2.
Responses given to the questions asked to assess the sleep pattern in school going children
| Question No | Question asked | Number (%) |
|---|---|---|
|
Information asked related to last night | ||
| 1 | What time did you go to bed last night? (n=218) Before 9:00 PM 9:00 – 11:00 PM After 11 but before midnight After mid night |
7(3.2) 128(58.7) 60(27.5) 23(10.6) |
| 2 | Once you turned your light off, how long did it take you to fall asleep last night? (n=229) Very quickly 5-10 minutes 10-30 minutes >30 minutes |
21(9.2) 136(59.4) 42(18.3) 30(13.1) |
| 3 | Did you take any medication to help you sleep last night? (n=231) Yes No |
6(2.6) 225(97.4) |
| 4 | After you fell asleep, did you wake up during the last night? (n=231) Yes No |
72(31.2) 159(68.8) |
| 5 | How long did it take you to go back to sleep after you woke up during the last night? (n=231) I did not wake up last night I went back to sleep very quickly In 5-10 minutes In 10-30 minutes After 30 minutes |
159(68.8) 40(17.3) 26(11.3) 5(2.2) 1(0.4) |
| 6 | What time did you wake up today? (n=231) Before 5:00 AM 5:00-6:00 AM 6:00-7:00 AM After 7:00 AM |
5(2.2) 100(43.3) 77(33.3) 49(21.2) |
| 7 | How did you wake up this morning? (n=231) I woke up by myself I woke up with an alarm Family member woke me up My pet woke me up |
91(39.4) 30(13.0) 107(46.3) 3(1.3) |
| 8 | How well did you sleep last night? (n=231) I had a great night of sleep I had a good night of sleep I had an okay night of sleep I had a poor night of sleep |
98(42.4) 88(38.1) 38(16.5) 7(3.0) |
|
Information asked related to weekdays when he/she goes to school | ||
| 9 | What time do you usually go to bed on weekdays? (n=231) Before 9:00 PM 9:00 – 11:00 PM After 11 but before midnight After mid night |
6(2.6) 126(54.5) 73(31.6) 26(11.3) |
| 10 | Once you turn your light off on weekdays, how long does it usually take you to fall asleep? (n=231) Very quickly 5-10 minutes 10-30 minutes >30 minutes |
29(12.6) 124(53.7) 64(27.7) 14(6.1) |
| 11 | What time do you usually wake up on weekdays? (n=231) Before 5:00 AM 5:00-6:00 AM 6:00-7:00 AM After 7:00 AM |
10(4.3) 60(26.0) 118(51.1) 43(18.6) |
|
Information asked related to weekends when he/she does not go to school | ||
| 12 | What time do you usually go to bed on weekends? (n=231) Before 9:00 PM 9:00 – 11:00 PM After 11 but before midnight After mid night |
6(2.6) 83(35.9) 80(34.6) 62(26.8) |
| 13 | Once you turn your light off on weekends, how long does it usually take you to fall asleep? (n=231) Very quickly 5-10 minutes 10-30 minutes >30 minutes |
30(13.0) 108(46.7) 69(29.9) 24(10.4) |
| 14 | What time do you usually wake up on weekends? (n=231) Before 6:00 AM 6:00-8:00 AM 8:00-10:00 AM After 10:00 AM |
23(10.0) 81(35.1) 81(35.1) 46(19.8) |
|
Information asked related to usual sleep on most days, including both weekdays and weekends | ||
| 15 | After you have gone to sleep at night, how often do you usually wake up during the night? (n=231) Almost every night (5-7 times/week) Several times a week (1-4 times/week) Every now and then (2-3 times/month) I almost never wake up during the night |
23(10.0) 40(17.3) 83(35.9) 85(36.8) |
| 16 | How long does it usually take you to go back to sleep after you wake up during the night? (n=231) I usually don’t wake up during the night I go back to sleep very quickly In 5-10 minutes In 10-30 minutes In more than 30 minutes |
69(29.9) 74(32.0) 73(31.6) 13(5.6) 2(0.9) |
| 17 | Some kids take naps in the daytime every day, others never do. Do you nap? (n=231) I never nap I never nap unless I am sick I sometimes nap I nap almost every day |
52(22.5) 26(11.3) 126(54.6) 27(11.7) |
| 18 | Most nights, do you feel you get…(n=231) Too much sleep? The right amount of sleep? Too little sleep? |
54(23.4) 144(62.3) 33(14.3) |
| 19 | Most nights, do you consider yourself to be…(n=204) a great sleeper? a good sleeper? an okay sleeper? a poor sleeper? |
50(24.5) 88(43.1) 58(28.4) 8(3.9) |
Sleep hygiene indices
There are four Sleep Hygiene Indices, namely Caffeine Index (CI), Activities Hour Before Bed Index (ABBI), Sleep Location Index (SLI), and Electronics Use at Sleep Onset Index (EUSI). The values of the four composite Sleep Hygiene Indices and each individual item from the indices for the overall participants, good versus poor sleepers, and junior versus senior grades are summarized in Table 3. The Electronics Use at Sleep Onset Index score was significantly higher (P < 0.01) among poor sleeper (7.2 ± 2.6) than good sleeper (6.1 ± 2.6) that indicated that poor sleepers where more commonly using electronic device at bed time; the score was comparable (P = 0.26) between junior (6.2 ± 2.7) and senior (6.6 ± 2.6) grade students. The overall Sleep Hygiene Index, as well as CI, ABBI, and SLI were not significantly different between good and poor sleeper [Figure 1a] or junior and senior grades.
Table 3.
Comparison of sleep hygiene indices between good versus poor sleeper and junior versus senior grades students
| Indices | Overall | Sleeper type |
Grade of study |
||||
|---|---|---|---|---|---|---|---|
| Good sleeper | Poor sleeper | P | Junior grade | Senior grade | P | ||
| Caffeine index (Caffeine containing drinks) Caffeine containing soda drink Iced tea/hot tea Coffee |
8.2±2.3 2.3±1.0 3.2±1.5 2.7±1.2 |
8.1±2.2 2.2±0.9 3.2±1.5 2.7±1.2 |
8.2±2.4 2.5±1.1 3.2±1.5 2.7±1.2 |
0.62 | 8.2±2.2 2.3±1.1 3.3±1.5 2.6±1.3 |
8.2±2.3 2.3±1.0 3.1±1.5 2.7±1.2 |
0.88 |
| Activities hour before bed index Have activities Text or social media Watch television or movies Play video or computer games Bath/shower Read books/magazines |
16.3±3.9 2.7±1.1 2.9±1.5 3.1±1.3 2.4±1.4 2.7±1.6 2.5±1.4 |
16.4±4.0 2.7±1.4 2.8±1.5 3.1±1.3 2.4±1.4 2.8±1.6 2.7±1.4 |
16.1±3.8 2.9±1.2 3.2±1.5 2.9±1.3 2.2±1.4 2.5±1.7 2.3±1.2 |
0.64 | 16.7±4.6 2.9±1.3 2.8±1.6 3.3±1.3 2.7±1.5 2.3±1.5 2.6±1.5 |
15.9±3.5 2.6±1.3 2.9±1.4 2.9±1.3 2.2±1.3 2.9±1.7 2.4±1.3 |
0.13 |
| Sleep location index Fall asleep sibling’s bed Fall asleep parents’ bed Fall asleep couch/other location Wake up sibling’s bed Wake up parents’ bed Wake up couch/other location |
14.4±4.3 2.8±1.5 2.8±1.4 1.9±1.2 2.6±1.5 2.7±1.5 1.8±1.2 |
14.4±4.1 2.9±1.6 2.8±1.4 1.9±1.2 2.6±1.6 2.8±1.5 1.8±1.2 |
13.9±4.5 2.6±1.5 2.8±1.5 1.9±1.2 2.5±1.6 2.5±1.5 1.7±1.2 |
0.46 | 14.9±4.2 2.8±1.5 3.1±1.5 1.8±1.1 2.5±1.5 3.0±1.6 1.8±1.2 |
14.2± 4.4 2.8±1.5 2.7±1.4 2.0±1.3 2.6±1.6 2.5±1.4 1.9±1.3 |
0.32 |
| Electronics use at sleep onset Television on in room Listen to music Light on in room |
6.5±2.7 1.5±1.0 2.9±1.5 2.0±1.4 |
6.1±2.6 1.4±0.9 2.8±1.5 1.8±1.3 |
7.2±2.6 1.6±1.0 3.1±1.4 2.4±1.6 |
<0.01 | 6.2±2.7 1.3±0.8 2.7±1.6 2.1±1.5 |
6.6±2.6 1.6±1.1 3.0±1.4 2.0±1.4 |
0.26 |
Data are expressed as mean±SD; Data are compared using t-tests
Figure 1.
Bar charts comparing (a) Sleep Hygiene Index (Caffeine Index, Activity Before Bed Index, Sleep Location Index, and Electronic Use at Sleep Onset) and (b) Sleep Disturbance Scale (Bedtime Fear/Worries Scale, Restless Legs Scale, Parasomnias Scale, and Insomnia Scale) between good and poor sleeper
Sleep disturbance scales
There are four Sleep Disturbance Scales, namely Bedtime Fear/Worries scale (BTFW), Restless Legs Scale (RLS), Parasomnias Scale (PS), and Insomnia Scale (IS). The values of the four Sleep Disturbance Scales, and individual items from these scales for the overall participants, good versus poor sleepers, and junior versus senior grades are summarized in Table 4. Compared to good sleepers, the poor sleepers had significantly higher values for BTFW (3.7 ± 1.7 versus 5.0 ± 2.2; P < 0.01), RLS (7.3 ± 2.6 versus 8.6 ± 3.5; P < 0.01), and IS (13.6 ± 2.8 versus 15.0 ± 3.3; P < 0.01) [Figure 1b]. All four scales were comparable between junior and senior grades.
Table 4.
Comparison of sleep disturbance scales between good versus poor sleeper and junior versus senior grades students
| Indices | Overall | Sleeper type |
Grade of study |
||||
|---|---|---|---|---|---|---|---|
| Good sleeper | Poor sleeper | P | Junior grade | Senior grade | P | ||
| Bedtime fears/worries scale Scared at sleep onset Upset/worried at sleep onset |
4.1±1.9 1.9±1.2 2.1±1.3 |
3.7±1.7 1.9±1.1 1.8±1.1 |
5.0±2.2 2.2±1.3 2.8±1.3 |
<0.01 | 3.9±1.8 2.0±1.2 1.9±1.1 |
4.2±2.0 1.9±1.1 2.3±1.3 |
0.26 |
| Restless legs scale Funny feeling in legs Legs bother at bedtime Have to move legs at bedtime Kicks legs when sleeping Move a lot during sleep |
7.7±2.9 1.7±1.0 1.5±0.9 1.7±1.2 1.3±0.6 1.5±0.7 |
7.3±2.6 1.6±0.8 1.5±0.8 1.6±1.2 1.3±0.6 1.4±0.6 |
8.6±3.5 1.7±1.0 1.8±1.1 1.8±1.4 1.3±0.5 1.6±0.8 |
<0.01 | 7.9±2.9 1.8±1.0 1.5±0.9 1.7±1.3 1.4±0.6 1.5±0.7 |
7.6±3.0 1.7±1.0 1.6±0.9 1.6±1.2 1.2±0.5 1.5±0.7 |
0.53 |
| Parasomnia scale Talk in your sleep Walk around/cry out during sleep |
2.4±0.7 1.3±0.5 1.1±0.4 |
2.3±0.6 1.2±0.4 1.1±0.3 |
2.5±0.8 1.4±0.5 1.1±0.4 |
0.12 | 2.4±0.7 1.3±0.5 1.1±0.4 |
2.4±0.8 1.3±0.5 1.1±0.4 |
0.94 |
| Insomnia scale Time taken to fall asleep Frequency of awakening during sleep Time taken to return to sleep Thinking about that day/next day Trouble falling asleep at bedtime Wake up during night |
13.9±3.0 2.4±0.8 3.0±1.0 2.2±0.9 2.5±1.4 1.8±1.0 2.1±1.1 |
13.6±2.8 2.3±0.8 3.1±0.9 2.0±0.9 2.4±1.4 1.7±0.9 2.0±1.0 |
15.0±3.3 2.5±0.8 2.8±1.0 2.4±1.0 2.9±1.4 2.1±1.2 2.2±1.2 |
<0.01 | 13.7±3.1 2.4±0.9 2.9±1.0 2.2±1.0 2.4±1.5 1.7±0.9 2.2±1.2 |
14.1±3.0 2.3±0.8 3.0±0.9 2.1±0.9 2.6±1.3 1.9±1.1 2.0±1.0 |
0.45 |
Data are expressed as mean±SD; Data are compared using t-tests. SD: standard deviation
Sleepiness scale and sleep disorder indicator items
The sleepiness of the participants while eating, playing, riding, talking, and in school are summarized in Table 5. Poor sleepers had higher sleepiness scores at school (2.3 ± 1.3) than good sleepers (1.1 ± 1.0) that suggested that poor sleeper were sleepier in school (P < 0.01). The sleepiness scores, while eating, playing, riding, and talking were comparable between good and poor sleepers, as well as between junior and senior grades. The Bed Wetting score was significantly higher (P = 0.02) among poor sleepers (1.2 ± 0.6) than good sleepers (1.0 ± 0.3). All Sleep Disorder indicators were comparable between junior and senior grades.
Table 5.
Comparison of sleepiness scale and indicator items between good versus poor sleeper and junior versus senior grades students
| Indices | Overall | Sleeper type |
Grade of study |
||||
|---|---|---|---|---|---|---|---|
| Good sleeper | Poor sleeper | P | Junior grade | Senior grade | P | ||
| CRSP sleepiness scale While eating While talking At school While playing While a car or bus for a short drive |
1.3±0.7 1.4±0.8 1.9±1.1 1.2±0.5 2.0±1.2 |
1.4±0.7 1.4±0.8 1.1±1.0 1.1±0.5 2.0±1.2 |
1.3±0.7 1.6±1.0 2.3±1.3 1.2±0.6 2.2±1.3 |
0.69 0.11 <0.01 0.27 0.36 |
1.4±0.8 1.4±0.8 2.1±1.2 1.2±0.6 2.0±1.1 |
1.3±0.7 1.5±0.9 1.8±1.0 1.1±0.5 2.1±1.3 |
0.34 0.41 0.13 0.18 0.69 |
| Indicators items Bed wetting Snoring while sleeping Having bad dreams |
1.1±0.4 2.2±1.0 1.2±0.5 |
1.0±0.3 2.2±0.9 1.1±0.4 |
1.2±0.6 2.4±1.1 1.2±0.6 |
0.02 0.11 0.14 |
1.1±0.4 2.3±1.1 1.2±0.5 |
1.1±0.4 2.2±1.0 1.1±0.4 |
0.78 0.75 0.40 |
Data are expressed as mean±SD; Data are compared using t-tests. SD: standard deviation
DISCUSSION
Translated CRSP-H had a response rate of 80% and questionnaire completion rate of 92% (231/250). Participants took about 20 min to complete the questionnaire. Mean daily sleep duration was 7.4 hours on week days and 9 hours on weekends. Higher classes were associated with significantly reduced sleep during the weekdays but not during the weekends. About two-thirds of the participants obtained sufficient sleep duration. Our survey revealed a large proportion of adolescents go to sleep between 9 and 11 pm, while two-thirds wake up during the night. We found that certain adolescents, though a small proportion, take the help of medication to induce sleep. Sleep Hygiene Indices were not grossly different between good or poor sleepers but Sleep Disturbance scores were worse in poor sleepers. Junior and senior grades students had comparable Sleep Hygiene Indices and Sleep Disturbance Scores.
Sleep is an essential physiological process that helps relax and regain our physical and mental strength but is more important for a child because it plays a crucial role in brain and cognitive development.[19,20] Sleep disturbances are widely recognized among children with neurological conditions[21,22,23] or non-neurological illnesses.[24] The high prevalence of sleep related problems has been reported among preschool[25] as well as school going children[26] from India and other countries.[27,28] Disturbance in healthy sleep is likely to adversely impact the development of a child. Hence, it is essential to identify sleep problems in childhood.
Over 183 tools have been developed for sleep assessment in children.[29] Unfortunately, most of these instruments are subjective in nature and assess the child’s sleep from the responses given by their parents to a set of questionnaires.[29] A recent systematic review suggest that parents’ have poor knowledge about the child sleep, particularly their sleep related problems.[9] Hence, it will be rather better to let the adolescent self-report their sleep related issues and problems. The CRSP is a self-reported instrument to assess the sleep pattern, hygiene, and disturbance in adolescents.
The CRSP had never been used in India because it was originally developed in English language and was never translated in Hindi language. We translated the CRSP in CRSP-H and used it for the first time in Indian children. We followed standard guidelines for translation followed by pre-testing in a separate set of participants before using the measure with study participants. CRSP-H is likely to be well accepted in community because it showed response rate of (>80%), ease of administration (>92% completion rate), and required only 20 min.
The translated instrument has relatively poor psychometric properties. Internal consistency between the items included in a particular domain, as assessed with Cronbach alpha, was poor. None of the Cronbach alpha value crossed 0.7, which is usually accepted as cut-off for good internal consistency in clinical studies. It may be because the questionnaire was developed in Europe and may need cultural adaptation f or Indian setting. This difference may also be due to gross difference in social and economic conditions of the two regions, which could affect the understanding and response of the participants. The correlation coefficient between the indices were also poor that may be because each domain was assessing a different aspect of sleep characteristics in children.
We found daily average sleep was curtailed in Indian children, particularly during the school days and only two-third of children were getting adequate sleep. Sleep may be disturbed due to environment such as excessive screen exposure,[30] growing academic requirements requiring late night studies, exposure to social media, or difficulty in falling asleep due restless leg syndrome,[31] parasomnias, or fear etc., This was reflected in our study as well. The poor sleepers showed worse more sleep disturbances as compared to good sleepers. Increasing grades of studies were associated with shorter duration of sleep that reflects the growing academic burden of children in present competitive era.
Several studies have reported sleep pattern and sleep disturbances among pre-school and school going children from India, but most of these studies were conducted in hospital setting[25,26,32,33] and data were collected from the parents but not the children. This is the first Indian study which collected data from the children using a self-administered questionnaire in a school setting. Prior studies, conducted in school setting, had used CSHQ completed by the parents.[34]
Our survey revealed a disturbing fact that a small proportion of adolescent require sleep inducing medications that could have long lasting physical and mental consequences. Use of sleeping pills, by the adults, are rapidly growing, which reflects the growing stress in our daily life and lifestyle. In the present era, children have also started using these drugs because of information from various sources, illegal availability of these drugs as over the counter medication, and presence of a role model in the family.
Our study has a few limitations as well. First, we did not validate the CRSP-H before its administration. Second, CRSP-H is a self-administered instrument and may not be useful for the children with limited opportunity for education. Third, the participants were recruited from a school located in urban setting may not be really representing the rural community. Fourth, our study had a relative underrepresentation of class X–XII students, in particular class XII and thus our results have limited application for students in class X–XII. On the hind side, inclusion of a fewer students from class X–XII students, who are deeply involved in preparation of competitive examination that could contribute to their sleep disturbance, made our results more realistic and less influenced by academic stress.
In conclusion, the use of CRSP-H is feasible for Indian adolescents. It will help us to understand more about the sleep habits, sleep patterns and sleep disturbances among youth. Combined with other measures this may also allow us to examine the impact of insufficient sleep duration, as well as social determinants of sleep in this population. Though, the currently translated version needs more adaptation to validation in Indian setting before it could be reliably used in clinical practice.
Ethics approval
Institutional Ethics Committee Era’s Lucknow Medical college and Hospital. Ref No.ELMC/R_Cell/EC/2016/188.
Conflicts of interest
There are no conflicts of interest.
Acknowledgement
Authors greatly acknowledge the (i) school authorities for permission to conduct this study (ii) Dr. Lisa Meltzer (Ph.D., CBSM), the original developer of CRSP English version for permission to use and translate it into Hindi language and for editing the manuscript (iii) the translators who helped in translation process.
Funding Statement
Nil.
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