AN EXPERIMENTAL EXAMINATION OF CHILDREN?S SLEEP QUALITY AND IMPROVEMENTS RESULTING FROM A PARENT EDUCATION INTERVENTION Except where reference is made to the work of others, the work described in this dissertation is my own or was done in collaboration with my advisory committee. This dissertation does not include proprietary or classified information. ________________________________________ Donna Golden Lee Certificate of Approval: _____________________________ _____________________________ Debra Cobia Joseph A. Buckhalt, Chair Professor Professor Counselor Education, Counselor Education, Counseling Psychology, and Counseling Psychology, and School Psychology School Psychology _____________________________ _____________________________ Robert Simpson Joe F. Pitman Profesor Interim Dean Rehabilitation and Special Education Graduate School AN EXPERIMENTAL EXAMINATION OF CHILDREN?S SLEEP QUALITY AND IMPROVEMENTS RESULTING FROM A PARENT EDUCATION INTERVENTION Donna Golden Lee A Dissertation Submitted to the Graduate Faculty of Auburn University in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy Auburn, Alabama August 4, 2007 iii AN EXPERIMENTAL EXAMINATION OF CHILDREN?S SLEEP QUALITY AND IMPROVEMENTS RESULTING FROM A PARENT EDUCATION INTERVENTION Donna Golden Lee Permission is granted to Auburn University to make copies of this dissertation at its discretion, upon request of individuals or institutions and at their expense. The author reserves all publication rights. ______________________________ Signature of Author ______________________________ Date of Graduation iv VITA Donna Golden Lee, granddaughter of the late Richard Pierce and the late Agnes Monceaux Golden, was born October 22, 1971, in Mobile, Alabama. She graduated from Fairhope High School with honors in 1990. In June 1994, she graduated Cum Laude from Auburn University in Auburn, Alabama with a Bachelor of Arts in Psychology and a minor in Family and Child Development. She earned a Master?s of Education with a focus on Emotional/Behavioral Disturbances in December 1995 from Auburn University. She worked as a consultative specialist and exceptional needs teacher for six years before pursuing her doctorate. While her area of focus was behavioral and emotional disturbance, she taught children identified with these and/or other exceptionalities including autism/pervasive developmental delay, mental retardation, specific learning disabilities, other health impairment, and students identified as gifted. She also worked with students identified as at-risk for drop-out. She has provided behavioral and consultative support to teachers, parents, and school administrators, as well as outside agencies and private institutions. She married Donald Andrew Lee, son of Samuel and Shirley Lee on November 7, 1998. On November 6, 2001, she gave birth to their first daughter, Daisy Makayla ?Ayla? Lee. Their second daughter, Laci Isabella Lee, was born May 1, 2004. Donna earned a Master?s of Education (Psychometry) in December 2003 and a Specialist of Education in School Psychology in May 2006 from Auburn University. She is currently employed by Auburn City Schools. v DISSERTATION ABSTRACT AN EXPERIMENTAL EXAMINATION OF CHILDREN?S SLEEP QUALITY AND IMPROVEMENTS RESULTING FROM A PARENT EDUCATION INTERVENTION Donna Golden Lee Doctor of Philosophy, August 4, 2007 (B.A., Auburn University, Auburn, AL 1994) (M.Ed, Auburn University, Auburn, AL 1995) (Ed.S, Auburn University, Auburn AL 2006) 138 Typed Pages Directed by Joseph A. Buckhalt The role of sleep in neurobehavioral functioning has been extensively studied. Empirical evidence has shown that functions of learning, memory, and emotional regulation can be influenced by sleep. A large number of children do not get adequate sleep and the consequences of poor sleep manifests in poorer behavior and attention regulation affecting academic performance and achievement. vi Using actigraphy and behavior scales, this study examined the sleep and behavior of six second-grade students before and after a parent sleep education program was provided as an intervention. Using a single-subject across multiple baselines experimental design, students were randomly placed in an order of receiving parent intervention. After one week of baseline, two families were provided the education program. After week two, another set of families received the intervention; after week three, the last set of families received the intervention. Teachers completed behavior rating scales for each school day during this 28-consecutive day study. Data analysis by means of descriptive statistics and graphical display indicated long-term change in four of five variables measuring sleep quality for one of six subjects, three of five variables for two subjects, two of five variables for one subject, and one of five variables for two subjects. Improvement is also indicated by an increase in variable frequency of achieving/exceeding baseline mean post-intervention. Lastly, of the five subjects whose teachers provided daily behavior ratings measuring attention, two subjects were shown to average higher scores following intervention. vii ACKNOWLEDGEMENTS The author would like to thank Dr. Joseph Buckhalt and Dr. Mona El-Sheikh for guidance and assistance throughout this study including the provision of actigraphic sleep monitors for this research. A genuine thank you to Bridget Wingo at Auburn University Sleep Lab for her extraordinary data downloading skills and patience. The author would like to thank Auburn City Schools for participating in this dissertation study. A special thank you goes to my friends Dr. Aleada Lee Tarver, Charity Crenshaw, Liz Knight, Kaye McDonough, and Dr. Nancy Golson who provided a world of support. To my husband and daughters, I love you. Thank you for allowing me to realize this life goal. Lastly, the author would like to thank the late Agnes Monceaux Golden for her presence and influence in my life. viii Style Manual: APA Manual Computer Software Used: ACTme Software Analysis Software Package (ActionW2, 2002) Microsoft Excel SPSS 12.0 for Windows ix TABLE OF CONTENTS LIST OF TABLES ........................................................................................................xii LIST OF FIGURES......................................................................................................xiv CHAPTER 1. INTRODUCTION.....................................................................................1 Research Questions..............................................................................................3 CHAPTER 2. LITERATURE REVIEW..........................................................................4 Sleep Overview....................................................................................................4 Sleep as a Biological Rhythm...............................................................................5 Biological/Physiological Mechanisms During Sleep.............................................7 Effects of Poor Sleep..........................................................................................10 Prevalence of Sleep Problems ............................................................................13 Causes of Sleep Problems ..................................................................................16 Sleep Intervention Research...............................................................................17 Bedtime Routines ...................................................................................18 Parent Education ....................................................................................19 Imposed Sleep Schedules........................................................................20 Purpose..............................................................................................................20 CHAPTER 3. METHODOLOGY..................................................................................23 Participants ........................................................................................................23 Measures............................................................................................................23 x Actigraphy..............................................................................................23 Sleep Diary.............................................................................................24 Daily Teacher Questionnaire ..................................................................24 Design and Procedure ........................................................................................24 Data Analysis Plan.............................................................................................27 CHAPTER 4. RESULTS...............................................................................................29 Overall Group ....................................................................................................29 Group Baseline and Post-Intervention ................................................................31 Individual Subject Values ..................................................................................33 Subject 1 ................................................................................................33 Subject 2 ................................................................................................35 Subject 3 ................................................................................................38 Subject 4 ................................................................................................40 Subject 5 ................................................................................................42 Subject 6 ................................................................................................44 CHAPTER 5. DISCUSSION AND CONCLUSIONS....................................................47 Sleep Variable Change.......................................................................................47 Behavior Change................................................................................................50 Comparison Between Boys and Girls .................................................................50 Pharmacological Effects.....................................................................................52 Limitations.........................................................................................................52 Conclusions .......................................................................................................54 Implications for Future Research........................................................................57 xi REFERENCES..............................................................................................................59 APPENDIX A. Auburn University Institutional Review Board (IRB) Approval ...........71 APPENDIX B. School Permission Forms.....................................................................73 APPENDIX C. Informed Consent Form .......................................................................78 APPENDIX D. Recruitment for Participation ...............................................................81 APPENDIX E. Data Collection Instruments .................................................................84 APPENDIX F. Intervention ..........................................................................................87 APPENDIX G. Statistical Tables..................................................................................92 APPENDIX H. Graphical Displays.............................................................................118 xii LIST OF TABLES Table 1. Group Overall Variable Data...........................................................................93 Table 2. Group Pre and Post-Intervention Data .............................................................94 Table 3. Subject 1 Variable Data...................................................................................95 Table 4. Subject 2 Variable Data...................................................................................96 Table 5. Subject 3 Variable Data...................................................................................97 Table 6. Subject 4 Variable Data...................................................................................98 Table 7. Subject 5 Variable Data...................................................................................99 Table 8. Subject 6 Variable Data.................................................................................100 Table 9. Subject 1 Baseline & Intervention Variable Data...........................................101 Table 10. Subject 2 Baseline & Intervention Variable Data..........................................102 Table 11. Subject 3 Baseline & Intervention Variable Data..........................................103 Table 12. Subject 4 Baseline & Intervention Variable Data..........................................104 Table 13. Subject 5 Baseline & Intervention Variable Data..........................................105 Table 14. Subject 6 Baseline & Intervention Variable Data..........................................106 Table 15. Individual Subject Weekly Mean Variable Values........................................107 Table 16. Sleep Variable Improvement by Period ........................................................108 Table 17. Subject 1 Improvement Over Baseline Analysis ...........................................109 Table 18. Subject 2 Improvement Over Baseline Analysis ...........................................110 Table 19. Subject 3 Improvement Over Baseline Analysis ...........................................111 xiii Table 20. Subject 4 Improvement Over Baseline Analysis ...........................................112 Table 21. Subject 5 Improvement Over Baseline Analysis ...........................................113 Table 22. Subject 6 Improvement Over Baseline Analysis ...........................................114 Table 23. Percentage of Days Meeting/Exceeding Baseline Mean................................115 Table 24. Daily Teacher Behavior Rating Scale Scores Summary by Subject...............116 Table 25. Descriptive Statistics for Comparisons Between Boys and Girls...................117 xiv LIST OF FIGURES Figure 1. Subject 1 Sleep Minutes...............................................................................119 Figure 2. Subject 2 Sleep Minutes...............................................................................120 Figure 3. Subject 3 Sleep Minutes...............................................................................121 Figure 4. Subject 4 Sleep Minutes...............................................................................122 Figure 5. Subject 5 Sleep Minutes...............................................................................123 Figure 6. Subject 6 Sleep Minutes...............................................................................124 1 INTRODUCTION According to the 2004 Sleep in America poll provided by the National Sleep Foundation, children in America do not sleep as much as experts recommend and a majority of children experience frequent sleep problems. The poll surveyed 1473 adults who were a primary caregiver or co-caregiver of a child 10 years of age or younger living within the same household, and found that a discrepancy exists in the number of hours children sleep and the number of hours parents think they should sleep. While the poll revealed that 69% of all children experience one or more sleep-related problems on a regular basis, only one in 10 parents thinks their child has a sleep problem. Of those, the poll found that many parents do not recognize their child?s sleep problems as a concern which should be addressed (NSF, 2004). Most sleep problems have been found to be exacerbations of normal sleep behavior caused by poor sleep hygiene, daytime stressors, or unusual sleep phenomena (Adair & Bauchner, 1993; Owens & Dalzel, 2005). This indicates a significant role for parent behavior in the development and maintenance of poor sleep in children. As studies continue to identify and further define the function of sleep, decades of researching sleep have provided a body of knowledge on sleep, including the role of sleep in child development and the effects of poor sleep on human functioning and well-being (Bonnet, 1994; Pilcher & Huffcutt, 1996; Sadeh, Gruber, & Raviv, 2002). There remains a paucity of sleep studies with typically developing children of school age. 2 Normative values for objective measures of sleep for this group are sparse. Yet, practical conclusions can be drawn from what is currently known about sleep. Significant to health, behavior, learning, and quality of life, optimal functioning is dependent on healthy sleep. The 2001 Transforming the Federal Role in Education so that No Child is Left Behind (No Child Left Behind) legislation calls to close the academic achievement gap between social class and ethnicity. This legislation includes measures to increase accountability for student performance, to focus on what works, to reduce bureaucracy and increase flexibility, and to empower parents. Now more than ever, standard test score results are scrutinized and effective, researched based programs and practices are being sought out. Educators and administrators are to help improve the academic achievement of the disadvantaged, increase parental involvement, create prevention and intervention programs for neglected, delinquent, or at-risk children, provide teacher training with evidence-based psychological principles into practice, and help unite psychological science with education. Parental education with regard to sleep holds much promise as a means to improve student performance. Positive results have been shown with parent training in areas such as sleep patterns, behavioral entrainment, and intervention methods for infant sleep. Evidence also exists supporting the efficacy of empirically based behavioral treatments for young children and adolescent sleep problems (Mindell, 1999; Mindell et al., 2006). If children experience healthy sleep habits, research shows that mood, performance, and behavior are positively affected (O?Brian & Gozal, 2004). This suggests that treatment of sleep problems may lead to an improvement in academic achievement in school-age children. 3 The prominent role of sleep in child development coupled with the high prevalence of sleep problems experienced in school-aged children and the consequences of poor sleep underlies the need for research to learn more about childhood sleep, it?s potential for change, and if parent education can positively affect child sleep. 4 LITERATURE REVIEW In order to understand sleep?s significant role during childhood and the need to determine if parent education with regard to sleep can influence the quality of sleep children experience, the following literature review will provide an overview of sleep, describe sleep as a biological rhythm and how this rhythm is associated with child development, describe underlying biological/physiological mechanisms which take place during sleep, effects of poor sleep, and prevalence of sleep disturbance experienced by children. Lastly, a review of sleep intervention studies will be provided. Sleep Overview Briefly defined, sleep is ?a natural, periodic state of rest for the mind and body, in which the eyes usually close and consciousness is completely or partially lost, so that there is a decrease in bodily movement and responsiveness to external stimuli? (American Heritage Dictionary, 1992). During sleep, the human brain undergoes a characteristic cycle of brain-wave activity. Some brain regions show the same (or increased) activity as when awake and includes intervals of dreaming (Dahl & Lewin, 2002). Considered to be a behavioral state of the central nervous system (CNS), sleep can be described as an expression of CNS function, which has specific properties that reflect a particular mode of CNS activity (Groome, 1997). In the 50 years of scientific study of sleep, a number of hypotheses have been generated on the functional significance of sleep. Theories have ranged from restorative, 5 protective, and energy conserving in nature, to serving a role in central nervous system arousal, protein synthesis, and physiological maintenance. More recent theories include memory consolidation and synaptic reorganization of the cerebrum (Blumberg & Lucas, 1990). Technological advances in tools used to study sleep such as actigraphy, polysomnography (PSG) and neuroimaging techniques continue to guide theory and research and contribute to our understanding of sleep. While sleep continues to pose a biological enigma, its functional significance can be illustrated in animal experiments where sleep deprivation eventually results in death (Rechtschaffen, Gilliland, Bergmann, & Winter, 1983; Wozniak, 2000). Sleep as a Biological Rhythm Appearing before birth and continuing throughout life, sleep and wake states are characteristic to both humans and animals (Thoman, 1990). The cycling of sleeping and waking is one of many rhythmic patterns in life (Wolf, 1962). Changing behavioral and physiological processes that reoccur at regular (roughly 24-hour) intervals are referred to as circadian rhythms (circa=about; dian=day). Circadian rhythms influence organization of activities into day and night cycles and the cyclic fluctuations associated with rest-activity cycles have been described to constitute a fundamental biological rhythm on which other daily rhythms are superimposed (Stern, 1969). All species, unicellular organisms to human, organize activities into day and night cycles, synchronizing physiological processes with the earth?s rotation (Tankova, Adan, & Buela-Casal, 1994). In humans, physical activity, sleep, body temperature, secretion of hormones, and more than one hundred other physiological processes are characterized by circadian 6 rhythms (Carlson, 1992; Stoudemire, 1990). They operate according to internal hereditary biologic clocks and are thought to be entrained by time cues, particularly by cognitive and social zeitgebers (factors that give time) (Kalat, 1992). As a child develops, patterns associated with these different rhythms change. With regard to sleep, age-related (developmental) processes exert profound influence. Total sleep decreases from 90% of a 24-hour period in infancy to just 8 hours per night by the age of 18 progressively taking on sleeping patterns characterized by shorter sleep duration, longer sleep cycles, and less daytime sleep as is characterized by adult sleep patterns (Dahl, 1996). Spending approximately equal amounts of time sleeping during the day and night, a neonate?s ?biological clock? takes a few months to catch on to the 24-hour cycle. Advances in neurological development during the first 6 months enable infants to remain awake and alert for longer periods of time as their patterns of sleeping, crying and eating become more regular (Bee & Boyd, 2002; Olds & Papalia, 1992). Gradually in the course of the baby?s first year, a transition to a more regular pattern of eating and sleeping occurs (Dearing, 2001). This regularity of sleep patterns marks the development of the central nervous system?s regulation of the circadian cycle of sleep and wakefulness (Sadeh & Anders, 1993; Thoman, 1990). Research findings have shown that many children do not establish an early, stable sleeping pattern and up to 30% of children have sleep problems in their first 4 years (Futterman, Lacks, & Wolfson, 1992). Moreover, sleep disturbances during the first years of life tend to persist and may develop into a chronic disorder. When understood in terms of context, time, and development, this is concerning. During the first 5 years of life, 7 during the developmental period where the brain triples in size to reach 90% of adult size and achieves exceptional complexity in cognition, socio-emotional development, language, concept of self, and physical skills, a child spends more time asleep than awake (Chugani, Phelps, & Maziota, 1987; Cicchetti & Beeghly, 1990; Kagan, 1981). Thus during this significant developmental period which spans childhood, sleep is arguably the primary activity of the brain and appears to serve a central role during development (Dahl, 1996). While much attention has been paid to a large number of factors during waking that relate to cognitive development, account for individual differences, and propel developmental change, sleep?s robust presence in childhood is not coincidental and the establishment and maintenance of a stable sleeping pattern is essential for optimal development. Attention to factors which take place during sleep will provide a better understanding of sleep?s significant role in human development and functioning. Biological/Physiological Mechanisms of Sleep In 1953, Aserinsky and Leitman identified two distinct sleep stages: REM sleep (Rapid-eye movement or dream sleep) and non-REM sleep, which are now generally accepted to frame the basic architecture of sleep. During sleep, we alternate between REM and NonREM phases of sleep. According to the National Sleep Foundation (on- line), ?sleepers go back and forth through various stages of sleep, all of which produce noticeable changes in brain activity and other physiological functions.? We begin our nights with NREM sleep. NREM sleep is comprised of four phases which correspond to progressively deeper levels of sleep. In a healthy and well-regulated individual, it takes 3-15 minutes after one closes their eyes to enter Stage 1 NREM sleep. 8 It is in this stage that one will sometimes experience myoclonic contractions, or little jerks associated with the impression of falling. Sleepers are easily awakened during this stage of sleep and if awakened, may not realize they were asleep. Once Stage 1 NREM is established, sleepers move towards Stage 2 NREM sleep. Lasting 10-15 minutes, this stage is still relatively light but produces bigger spikes in brain waves than Stage 1 NREM. After Stage 2, sleepers move to Stage 3 and then Stage 4 NREM sleep. Stages 3 and 4 NREM are also called delta or slow-wave sleep and represent the deepest sleep in humans. As Dahl (1996) notes, ?It is during this slow-wave sleep, (usually 1 to 3 hours after going to sleep) that it is extremely difficult to arouse children and if aroused, children appear disoriented, confused, and are cognitively slow.? Sleepwalking, talking, and night terrors are usually associated with this stage of sleep. The length of deep delta sleep is regulated by the wake state. ?It increases in proportion to how long one has been awake and further increases (and becomes even deeper) following sleep loss or chronic sleep disturbances (as a deep ?recovery? sleep)? (Dahl, 1996). Delta sleep is followed by REM sleep, also called paradoxical sleep because it has aspects of both deep sleep and light sleep. This stage of sleep is characterized by rapid eye movements and paralysis of muscles other than those controlling the eyes and those maintaining breathing. It is also characterized by intense neural activity, an increase in blood circulation, and an increase in the use of oxygen. Dahl and Lewin (2002) describe the paradoxical nature of this stage of sleep: On one hand, REM appears deep because the changes in the body (loss of muscle tone) and subcortical brain systems, such as temperature regulation and control of respiration and heart rate, are more profound than in any other stage of 9 sleep. On the other hand, higher cortical brain functions are associated closely with REM sleep. Further, it is relatively easy to awake a person from REM sleep (alertness returns relatively briskly, compared with deep non-REM sleep). (p6) In a healthy, well-regulated individual, the longest and most intense REM periods are described to occur just after the body temperature reaches a minimum (around 5 am). When a person is awakened from REM sleep, alertness returns relatively fast. After REM sleep is over, the sleeper goes back to stage 2 NREM to begin the cycle again. A complete cycle lasts approximately 90 minutes and occurs four to six times throughout the night (Dahl, 1996). Like the development of regulation of the circadian cycle of sleep and wakefulness, sleep architecture and stage distribution are also influenced by maturation changes and age. Children have extremely large amounts of deep, slow-wave sleep. This high proportion of slow wave sleep peaks in early childhood and then decreases dramatically after puberty, and continues to decline over the lifespan. As well, there is a dramatic decrease in the proportion of REM sleep from birth (50% of sleep) through early childhood into adulthood (25-30%) (Carskadon, 1982). In addition to changes in brain waves during each stage of sleep, The National Sleep Foundation describes some of the important biological/physiological mechanisms which occur during sleep: During sleep, the body secretes a number of necessary hormones that affect growth, regulate energy, and effect metabolic and endocrine functions. For example, near the end of the sleep period, the body secretes the stress hormone cortisol, which stimulates alertness. Sleep is also the time when growth hormone 10 is secreted, which drives childhood growth and plays an important part in regulating muscle mass in adults. Further, the sleep cycle affects secretion of the hormone, leptin. This hormone tells the body when it should feel full and thus, has a direct influence on appetite and weight. (http://www.sleepfoundation.org) What is important to note here is that there appears to be a very specific pattern to these processes, as when or what stage of sleep specific physiological or biochemical processes occur. Further, sleep characteristics including continuity, timing, and patterning of different stages of sleep are described to affect these processes. If sleep is repeatedly interrupted and one cannot cycle normally through REM and NREM sleep, sleepiness or fatigue will be experienced during the day (Dahl & Lewin, 2002). If sleep gets interrupted at night or gets cut short in the morning, or even if one sleeps many hours in short pieces of interrupted sleep, consequences of sleep dysfunction will be experienced. Consequences to cumulative sleep deprivation without cycles of REM and NREM can include depression, confusion, memory loss, extreme mood swings, anxiety, hyper- somnolence, hallucinations, and other personality changes (Hobson & Pace-Schott, 2002). So, while the function of sleep continues to be scientifically unraveled, we know that there are specific biological/physiological mechanisms which occur during sleep whose regulation are affected when one has poor, insufficient or interrupted sleep. Effects of Poor Sleep The effects of inadequate and/or disrupted sleep on children?s health, behavior, learning, cognition, emotional well-being, and quality of life can be serious and pervasive (Owens & Witmans, 2004; Wolfson & Carskadon, 2003). Inadequate or disturbed sleep results in significant daytime sleepiness for children and adolescents and significant 11 performance impairments and mood dysfunction are associated with daytime sleepiness (Fallone, Owens, & Dean, 2002; Owens & Witmans, 2004). Sleepiness has been associated with child functioning in such domains as inattention, poor concentration, hyperactivity (Chervin, Dillon, Bassetti, Ganoczy, & Putich, 1997; Epstein, Chillag, & Lavie, 1998), poor school performance (Wolfson & Carskadon, 2003), impaired cognitive test performance (Buckhalt, El-Sheikh, & Keller, 2007), poor performance on standardized achievement tests (El-Sheikh, Buckhalt, Cummings, & Keller, 2007), and irritability and aggression (Dahl, 1996). Inadequate sleep results in mood deterioration, decreased arousal, difficulties with focused or controlled attention, and fatigue. In addition, irritability and decreased threshold for negative emotional responses such as anger and frustration are also often associated with sleep deprivation (Dahl 1996). As reported by Owens and Witmans (2004): Mood problems in children with sleep disturbances are virtually universal, particularly exacerbation of negative mood and equally importantly, a decrease in positive mood or affect. The regulation of mood, or the use of cognitive strategies to modulate and guide emotions, appears to be affected by sleep quality and quantity. (p.155) Furthermore, Dahl and Lewin (2002) note that there is ?mounting evidence that sleep deprivation has its greatest negative effects on the control of behavior, emotion, and attention, a regulatory interface that is critical in the development of social and academic competence, and psychiatric disorders? (p. 175). Both subjective and objective measures have found that children who are characterized as poor sleepers show increased incidence 12 and severity of behavioral difficulties; with more disturbed sleep measures, more altered behavior is found to be observed (O?Brian & Gozal, 2004). Poor, insufficient, or disorganized sleep has been linked to poor academic performance (Epstein, Chillag, & Lavie, 1998; Gozal, 1998; Randazzo, Mueuhlbach, Schweitzer, & Walsh, 1998; Wolfson & Carskadon, 1998). School-age children?s performance in school is greatly affected by their quality of sleep, duration of sleep, sleeping patterns, and their sleeping behaviors. In their 2002 study, Sadeh, Raviv, and Gruber found significant correlations between poorer sleep-quality measures, lower performance on neurobehavioral functioning measures and higher rates of behavior problems in school age children. Wolfson and Carskadon (1998) found that students who described themselves as struggling or failing school (Cs, D?s, and F?s) reported that on school nights they obtained about 25 minutes less sleep and went to bed an average of 40 minutes later than those students who described themselves as A & B students. It must be noted that causal relationships between sleep problems and children?s well-being appears to be bidirectional (Dahl, 1996; Sadeh 1996). Sleep problems can be indicative of child psychopathology or stress, and psychopathology can result from or be exacerbated by poor sleep (Sadeh, Raviv, & Gruber, 2000). Agreeing, Dahl (2002) notes: It is essential to underscore the overlap between sleep regulation and behavioral/emotional problems in children and adolescents because there is a clear two-way interaction between these systems. The development, regulation, and timing of sleep can be altered by behavioral/emotional disorders, and cognitive, behavioral/emotional control during daytime hours can be influenced by the way children and adolescents sleep. (p181) 13 Owens and Witmans (2004) report that even among special populations where the clinical symptoms of any primary medical, developmental, or psychiatric disorder are likely to be exacerbated by comorbid sleep problems, improving sleep has the benefit of improving clinical outcomes. For instance, treatment for sleep problems has been found to improve ADHD symptoms in children identified with ADHD (Dahl, 2002; Mullane & Corkum, 2006; Cohen-Zion & Ancoli-Israel, 2004). Sleep restriction and extension research has provided support to the efficacy of sleep intervention on performance. Sadeh, Gruber, and Raviv (2003) restricted or extended children?s sleep by one hour over three nights. Measuring cognitive functioning with the Neurobehavioral Evaluation System, results showed that moderate changes in sleep duration to have significant positive effects on children?s neuropsychological functioning suggesting that most children can benefit from even modest sleep extension. Likewise, a within-subjects experimental design with one week of baseline, one week of sleep restriction, and one week of sleep optimization, found that when sleep was restricted, children were rated by teachers to have more academic problems compared to the other conditions and more attention problems compared with the baseline condition (Fallone, Acebo, Seifer, & Carskadon, 2005). Prevalence of Sleep Problems Reported prevalence rates of sleep problems have ranged from less than 5% to 43% in school-aged children (Mindell, Carskadon, & Owens, 1999; Ohazon, Roberts, Zulley, Smirene, & Priest, 2000; Stein, Mendelsohn, Obermeyer, Amromin, & Benca, 2001; Rona, Gulligord, & Chinn, 1998; Kahn et al., 1989). Until recently, it has been difficult to provide accurate estimates of the prevalence of specific sleep problems 14 in the school-age child because most studies have used either subjective reports or the criteria used to identify the exact nature of the problem were not well defined. For instance one study reported prevalence rates lower than 5% (Rona, Gulligord, & Chinn, 1998) while Owens, Spirito, McGuinn, & Nobile (2000) reported 37% and Archbold, Pituch, Panahi, & Chervin (2000) reported rates as high as 41%. The more recent use of objective measures such as actigraphy to measure sleep, has provided more accurate estimates of the number of children experiencing sleep problems. Activity-based monitoring has been established as a valid and reliable method of assessing sleep-wake patterns in children and adolescents. Agreement rates between acticgraph measures and concurrent polysomnography (PSG) range from 78 to 90 percent for children, adolescents, and adults. In addition, studies have shown that actigraphy paired with parent sleep diaries and reports can provide an accurate picture of sleep duration and quality (Acebo, et al., 1999; Sadeh, Lavie, Scher, Tirosh, & Epstein, 1991; Wolfson et al., 2003). By measuring nighttime movement, actigraphy provides a variety of different objective parameters, including sleep onset latency, estimation of true sleep time, and fragmented sleep. With the use of actigraphy, Tikotzky and Sadeh (2001) determined that 41% of a sample of kindergarten children were poor sleepers according to at least one actigraphic criterion, and 29% had true sleep time lower than 90% (of time in bed). Another study using actigraphy showed that 18% of a community sample of 7- to 12-year olds manifested fragmented sleep, meaning sleep that is intermittent or noncontinuous throughout the night. One important finding from this study is that for most of those children identified with significant sleep problems, no sleep problem was identified or 15 reported by the parents or the children themselves even after a follow-up inquiry (Sadeh, Raviv, & Gruber, 2000). In a study of 600 eight-year-olds, regular delay of sleep onset was reported by 45% of children and only 17% of their parents (Gregory, Rijsdijk, & Eley, 2006). Like the 2004 Sleep in America poll, these latter two studies illustrate how many parents do not recognize their child?s sleep problems or if they do, they do not think it is an issue to be addressed. In addition, parents may know when their child goes to bed but are not aware when they actually go to sleep or if they wake during the night. In fact, older children are less likely to draw somebody's attention to their sleep problems (Anders, Carskadon, Dement, & Harvey, 1978). Most school-age children between 5 and 12 years old need between 10 and 11 hours of sleep (National Sleep Foundation, 2004). Daytime sleepiness in an elementary school?age child is indicative of significant sleep problems because physiologic alertness levels in this age group are normally very high (Owens & Witmans, 2004). For the school-aged child, the most common sleep problems include difficulty falling asleep, nighttime awakening, snoring, stalling and resisting going to bed, having trouble breathing, and fatigue complaints (Blader, Koplewicz, Abikoff, & Foley, 1997). Children with developmental disorders (Autism, Pervasive Developmental Disorder, and other neurobehavioral disorders) have been shown to be more likely to exhibit disorganized or disturbed sleep than other children (Piazza, Fissher & Kahng, 1996; Quine, 1991, 1992; Wiggs & Stores, 1996a, 1996b). As a result, they may be at risk for compromised neurobehavioral functioning contributing to the 16 academic difficulties experienced by some of these groups (Sadeh, Gruber, & Raviv, 2002). Causes of Sleep Problems School-age children in the United States and other technologically advanced countries are at risk for sleep problems due to a wide variety of cultural and psychosocial influences. Performance demands resulting from participation in a range of activities outside of school influence healthy sleep habits. Many school age children participate in after school programs and extracurricular sports and activities. In addition to such social/performance demands, demands and characteristics of home life may also contribute to poor sleep hygiene. Days are busier and not always consistent with time home, dinner, and bedtime routines. Household characteristics such as high levels of disorganization, crowding, and conflict are not conducive to good sleep. Cultural influences such as sleeping arrangements, appropriate sleeping patterns, and bedtime rituals also influence child sleep. Buckhalt, El-Sheikh, and Keller (2007) found that actigraphic measures for children?s sleep quality, duration, and variability in sleep schedules were related to a child having his or her own room as well as the number of persons who shared the child?s bedroom. Further, many children have television, radios, telephones/cell phones, and computers in their bedrooms. Research has found that the availability of such contemporary technological devices contribute to poorer sleep habits in children (Owens, Maxim, & McGuin, 1991; Van den Bulck, 2004). 17 A number of dominant sources of psychosocial influences outlined by Sadeh, Raviv, and Gruber (2000) included: (a) Parental characteristics, personality, psychopathology, education, and parenting skills (Morrell, 1999; Rona et al., 1998; Sadeh & Anders, 1993; Van Tassel, 1985); (b) psychosocial stress and trauma; (for reviews, see Moore, 1989; Sadeh, 1996) and (c) cultural and social demands and attractions, school, work, and entertainment (Carskadon, 1990; Wolfson, 1996; Wolfson & Carskadon, 1998). (p.292) In a review of the literature, Adair and Bauchner (1993), found that most sleep problems are either exacerbations of normal sleep behavior caused by poor sleep hygiene or daytime stressors or unusual sleep phenomena. They found that sleep-related problems are infrequently caused by unsuspected neuropathology such as seizures or narcolepsy. Sadeh, Raviv, and Gruber (2000) found that sleep quality measures (sleep percentages and number of night wakings) were associated with the parents? education and family stress. Children of parents with higher education level had improved sleep quality. Conversely, increased family stress was associated with poorer sleep quality. Sleep Intervention Research Over the last two decades, researchers and clinicians have developed a number of intervention strategies for bedtime behavioral issues, night wakings, and child/adolescent insomnia, including behavioral management techniques, parent education and medication (Mindell et al., 2006). While there is a paucity of experimental studies on the effectiveness of parent intervention on school-age child sleep 18 problems, evidence exists for empirically based behavioral treatments for infant and young children as well as approaches for adolescent sleep problems (Kuhn & Elliott, 2003; Mindell 1999, Mindell, et al., 2006; Owens 1999). Behavioral treatments have included ignoring procedures, bedtime routines, scheduled awakenings, sleep restriction, and parent education. In their 2006 review, Mindell and colleagues report extinction techniques and preventative parent education to be most strongly supported by evidence-based research. For the purpose of this review, research investigating the effectiveness of bedtime routines, parent education, and compliance and experimental success with imposed sleep schedules is examined. Bedtime Routines. To reduce tantrum behaviors, the development of positive bedtime routines as an alternative to ignoring was investigated (Rapoff, Christophersen, & Rapoff, 1982). Participants in this study included three developmentally delayed children ages 2, 4, and 15. The researchers found positive routines increased cooperation in going to bed, reduced the number of minutes past the appropriate bedtime, and reduced the duration of in-bed crying with all three children. In another study, bedtime routines and graduated extinction (gradually longer and longer periods of ignoring) was compared for their effectiveness at reducing bedtime tantrums. In this study, 36 children were randomly assigned to one of three groups: routines, graduated extinction, or control. From parental reports, children in both treatments groups had tantrums less often and for shorter periods of time than the control children, but routines produced the fastest improvements (Adams & Ricket, 1989). Using positive routines and sleep restriction in order to reduce bedtime disturbances and night waking, Christodulu and Durand (2004) examined the effectiveness of positive bedtime routines and sleep restrictions with four 19 young children with developmental disorders who experienced significant sleep problems. Results showed that bedtime routines and sleep restriction were successful in eliminating bedtime disturbances and nighttime awakenings with all four subjects. Parent Education. Efficacy of parent education on child sleep has shown promise. A majority of studies have been preventative in nature and show that parent education in child sleep does, in fact, make a difference. Three large studies have demonstrated the efficacy of parent education for the prevention of sleep problems. Wolfson, Futterman, and Lacks (1992) randomly assigned 60 first-time parents enrolled in childbirth classes to a sleep training group or a control conditioning. The training group received four training sessions, two prenatally and two post birth. Utilizing parental diary data, they found at age 6-9 weeks, infants in the parent training group slept significantly better than children in the control group. Adair, Zuckerman, Bachner, Phillip, and Levenson (1992) also demonstrated the efficacy of an education prevention program based on behavioral strategies. One hundred and sixty-four consecutive infants presenting at a 4-month health visit comprised the intervention group and were compared to 128 historical controls. At 9 months, the control group was twice as likely to wake during the night compared with the intervention group. Lastly, Kerr, Jowett, and Smith (1996) found that parents of 3-month olds who were provided information about sleep issues had significantly fewer sleep problems at 9 months than a control group. The 169 children were randomly assigned to the intervention or control group. The parental intervention was provided both verbally by a researcher, and through written materials. 20 Parent education with regard to intervention has also shown success. Rapoff, Christophersen, and Rapoff (1982) studied the effectiveness of the use of management procedure guidelines for child sleep problems. In this study, nurse practitioners offered the management procedure guidelines during a single clinic visit and gave parents a written handout which described procedures for managing bedtime problems. Results showed that three of the six subjects showed a decrease in the rate of bedtime resistance (crying and whining) following treatment. Imposed Sleep Schedules. Some evidence exists for compliance and experimental success with imposed sleep schedules. Sadeh, Gruber, and Raviv (2003) found that given a small incentive, most children can extend or restrict their sleep period on demand. In another study, an assessment of compliance and experimental success with imposed sleep schedules among healthy children was completed. Fallone, Seifer, Acebo, and Carskadon (2002) asked children to follow assigned sleep schedules at home. Students were scheduled optimized (at least 10 hours time in bed per night) and restricted (6.5 to 8 hours in bed per night) sleep conditions across a 2 week period during the school year. Using continuous actigraphy and parent report of bedtime, researchers found children as young as 6 years of age were able to maintain substantial changes to their usual schedules across several nights at home. Purpose of this Study The increasing emphasis on accountability for schools has driven the field?s desire to seek new ways to help children do their best in school. This emphasis amplifies the importance of bridging science and education. Research implies that not only are children in America not getting the recommended amount of sleep, but they are also 21 experiencing other sleep problems as well. The literature supports that insufficient or poor sleep results in poorer behavior and attention regulation directly impacting academic performance and achievement. Conversely, research also shows that good sleep hygiene can foster healthy sleep which positively influences mood, performance and behavior. The National Sleep Foundation, in its ?Call to Action? recommends that parents and caregivers make sufficient sleep a family priority, embrace good sleep habits, learn to recognize sleep problems, and to talk with the pediatrician regarding sleep. Research has established that parents have a profound influence on their children?s sleep habits. Owens and Witmans (2004) offer some basic principles of sleep hygiene for both the child population and adolescent population. All principles such as routine setting, bedroom environment, child diet and exercise are under the direct control of parents. If parents are made aware of these principles, of the recommended hours of sleep, learn to recognize sleep problems, and the consequences of poor sleep, will child sleep be affected? Will child behavior be affected? It was hypothesized that a parent intervention in the form of sleep education would influence parent behavior resulting in positive changes in child sleep amount and quality and higher teacher ratings on measures of attention. Much of what is known about sleep is based on adult sleep and adult sleep disorders (NIH, 2003; Presman & Orr, 1997). A number of studies have focused on infant and early childhood sleep, both normal and impaired, but less research has been done with school-age children, and even less with typically developing, healthy children (Mindell, Owens, & Carskadon, 1999). Normative values for objective measures of sleep 22 for typically developing children are sparse. To date, most studies using school-age children have been outcome or correlational in nature with only a few experimental designs. Of those experimental designs, few have been developed to measure sleep changes with relation to an intervention program. 23 METHOD Participants Six second-grade students participated in this 28-consecutive day study. The Institutional Review Board for the Protection of Human Subjects (IRB) at Auburn University approved the study. Three students were male; three students were female. One male was identified as being diagnosed with ADHD and took 54 mg of Concerta daily. Another male was identified as taking 18 mg of Concerta for ADHD-like symptoms but was not diagnosed with ADHD. All students were of Euro-American ethnicity. Measures Actigraph. Actigraphs are small solid-state computerized movement detectors which continuously register body movement. Activity between bedtime and wake time was monitored, and daily sleep diaries were completed by the parents to cross-validate sleep start and end times. The actigraph was an Octagonal Basic Motionlogger (Ambulatory Monitoring Inc., Ardsley, NY), a small and lightweight (45g) sleep device the size of a wristwatch. Motion during sleep was continuously monitored by the actigraph in 1-min epochs using zero crossing mode. Sleep schedule measures were: (a) SOT, Sleep Onset Time - the first minute of three consecutive minutes of sleep as indicated by the Sadeh Algorithm; (b) DUR, the entire sleep period duration (in minutes) from sleep onset to sleep and end time; (c) SEF, 24 sleep efficiency defined as time spent asleep out of the total sleep period; and (d) WAKE, the number of awakenings longer than 5 minutes. Sleep quality was determined using measures of efficiency, awakenings, and motor activity. Sleep quantity was measured using values of total sleep minutes (the minutes scored as sleep by actigraphy) and sleep duration (time in bed). Sleep Diary. In order to document time to bed at night and morning wake time, this diary was provided for each night of the study. The diary includes a place to document additional sleep information, meal/caffeine intake, and other activities for each day. It was utilized while downloading sleep data and when providing feedback to parents. Research has shown that when paired with actigraphy, an accurate picture of sleep duration and quality may be obtained in the home over an extended period of time. (Acebo, et al., 1999; Sadeh, Lavie, Scher, Tirosh, & Epstein, 1991; Wolfson, Hafer, & Carskadon, 1999; Wolfson et al., 2003). Daily Teacher Questionnaire. A likert-type 4-question scale (1=never, 4=always) measuring observed student attention: alertness, on-task, focus, and concentration. This scale was completed daily by each student?s classroom teacher. Design and Procedure Flyers offering a free ?Sleep Check-up? were disseminated among children in second grade within a local school system. Contact information was provided on the flyer for those parents interested in learning more about participating. Upon responding, interested parents were informed that the ?Sleep Check-Up? was offered as part of a dissertation research study. In addition, parents were informed that their child?s participation and results of the ?sleep check-up? would be strictly 25 confidential, that no individual child or family would ever be identified. A detailed description of the study including the length of the study (four weeks), use of actigraphy monitoring, a daily sleep diary, and daily teacher rating scales was provided. The parents were also informed that at some point during the study, they would be provided a power- point presentation on sleep in school-age children. Parent questions were solicited. If interested in participating, parents completed a short questionnaire by phone about their family demographics and their child?s sleep. The questionnaire was developed from the BEARS brief screening instrument designed for pediatricians to interview parents and children (ages 2-18) as part of taking a sleep history. Questions asked fell into the five BEARS domains: Bedtime Problems, Excessive Daytime Sleepiness, Awakenings During the Night, Regularity of Sleep/Wake Periods, and Average Length of Sleep (Owens & Dalzell, 2005). Students chosen to participate had the highest degree of sleep difficulties as reported by parents on the initial questionnaire. Three hundred ninety flyers were sent home with 2 nd grade students. Eight families responded with a phone call for a response rate of 2.6%. Seven families completed the initial questionnaire. Chosen participants were contacted by phone. Confidentiality was reviewed again as well as requirements for participation. If still interested in participating in the study, parents agreed to allow their child to wear the actigraph watch for 4 weeks, keep a daily sleep diary for each day of the study, agreed to a one-hour educational PowerPoint presentation on sleep, and gave permission for their child?s teacher to complete a daily behavior scale for the duration of the study. After the parents and children gave consent, teachers were contacted with regard to completing daily behavior scales. 26 On the day that data collection began, parents were given the actigraph watch and diary. Instructions for the actigraph (when to put it on and take it off) and diary completion were reviewed, contact information was provided, and meeting times for data download was scheduled as well as times for intermittent phone calls to ensure completion of the daily sleep diary and provide opportunities for parent or student questions. During each night of the four weeks of data collection, each student wore the actigraphic monitors and parents completed the daily sleep diary. Parents were contacted by phone weekly. The sleep diary and actigraph were dropped off and picked up at an agreed upon time and location after each consecutive 7-day wearing of the actigraph so that data could be downloaded. Teachers were emailed a four-question behavior scale each day. Students were randomly placed in an order of receiving parent intervention. After one week of baseline, two families were provided the sleep education PowerPoint presentation. After week two, another set of families received the intervention. After week three, the last set of families received the intervention. After the 4 th week, actigraphs were collected. One week prior to intervention, the families were notified. Each family was given a choice of attending a one-on-one PowerPoint presentation with the presentation emailed and a hard copy sent home or not attending a one-on-one presentation but receiving the program by email and a hard copy of the presentation. A single subject across multiple baseline experimental design was used. Actigraphic raw data were downloaded and transformed into the pertinent sleep variables via the Octagonal Motionlogger Interface with ACTme Software, and the 27 Analysis Software Package (ActionW2, 2002). These sleep/wake measures have been demonstrated to have validity in calculations of sleep parameters, including those for children, when compared with polysomnography (Sadeh, Sharkey & Carskadon, 1994; Sadeh, Acebo, Seifer, Aytur & Carskadon, 1995). Procedures for setting times for sleep onset followed a lab protocol developed at the E.P. Bradley Hospital Sleep Laboratory at Brown University (Acebo & Carskadon, 2001). Movement at a threshold level for a period of time based on the Sadeh scoring algorithm is scored as ?awake? or ?asleep? (Sadeh et al. 1995; Sadeh et al. 1994). Very good reliability and validity for actigraphic measures have been reported (Acebo, et al. 1999; Sadeh et al. 2002). Once the information from the actigraph was downloaded and analyzed, parents were provided the results and resources including contact information for local sleep labs. Data Analysis Plan Data were analyzed using graphical display and descriptive statistics. For the purpose of this study, five variables measuring sleep were examined: Sleep Minutes (total minutes scored as sleep), Sleep Efficiency (100* Sleep Minutes/O-O Duration), Sleep Duration (Minutes from start to end of interval), Wake after Sleep Onset (Wake minutes during the O-O interval), and Activity Index (% epochs with >0 activity score). A behavioral measure calculated using daily scores from teacher completed behavior scales was examined as well. Total group and individually generated actigraphy and behavioral data were first examined to provide overall normative values for the 28-consecutive days of data collection. Variable values were then broken down for pre and post-intervention comparisons. Individual subject data were further examined for weekly average 28 comparisons and determining each subject?s frequency of meeting or exceeding baseline mean variable values post-intervention. 29 RESULTS Group values will first be presented followed by individual subject data. Individual subject data will be supplemented with information from parent-completed daily sleep diaries. Efficacy of intervention will be determined by post-intervention increase in mean values measuring sleep minutes, sleep efficiency, and sleep interval duration; decreased values measuring wake minutes after sleep onset and activity index. Improvement will also be indicated when the frequency of meeting or exceeding baseline mean values increase post-intervention. For the purpose of this study, long-term variable improvement for each subject will be proposed when variable improvement is shown both when comparing post-intervention and baseline period and when comparing the last week of data collection to that of the baseline period. Overall Group Values Table 1 shows that for this 28-day study, group values included 157 measures generated for 4 of the 5 sleep variables: Sleep Minutes, Sleep Efficiency, Sleep Duration, and Wake After Sleep Onset. There were 156 measures for the Activity Index variable (one measure was lost during data download). Subject 1 wore the actigraph 25 of the 28 days; Subject 2 , 27 of the 28 days; Subject 3, 27 of the 28 days; Subject 4, 25 of the 28 days; Subject 5, all 28 days; and Subject 6, 25 of the 28 days. Reasons for not wearing the actigraph included forgetting to put the watch on or spending the night away from home. 30 Over the course of the study, the group (N=6) averaged 459.968 (SD 60.331) minutes of sleep per night (7 hrs, 40 min). The minimum minutes of sleep at night was recorded as 255 minutes (4 hrs, 15 min) while the maximum was recorded as 593 minutes (9 hrs, 53 min) producing a range of 338 minutes (5 hrs, 38 min). The average group efficiency value was 88.20% (SD 6.88). The minimum efficiency value was 63.39%; the maximum value was 99.58%. The average duration of sleep (time in bed) was 523.89 minutes (SD 60.099; 8 hrs, 44 min). The range of values for duration was 397 minutes with a minimum value of 348 (5 hrs, 48 min) minutes and a maximum value of 745 minutes (12 hrs, 25 min). For the group, wake after sleep onset averaged 61.68 minutes (SD 36.80) for the 4-week study. The lowest value for wake after sleep onset was recorded as 2 minutes, while the highest was 217 minutes. Lastly, the average activity index for the duration of the study was 41.87% (SD 9.642) with a range of 21.06% to 67.94%. Teacher-completed behavior scales were completed for 5 of the 6 subjects. The classroom teacher for Subject 6 did not participate. The teachers generated a total of 69 measures. Of the possible 20 measures for each subject, subject 1 had ten; subject 2 had seventeen measures; subject 3 had sixteen; subject 4 had fourteen; and subject 5 had seventeen of the possible 20 measures. Reasons for not completing a daily behavior scale included the teacher forgetting or absenteeism. The average rating of student attention was 11.23 (of 16) with a standard deviation of 2.58. Scores ranged from 6-16 points. 31 Group Baseline and Post-Intervention Values Table 2 shows that for the group, mean minutes of sleep during baseline was 459.05 minutes. The post intervention average was 460.85. This shows an increase of 1.80 minutes. The minimum value for sleep minutes increased from 255 minutes during baseline to 270 minutes after intervention. The group?s mean sleep efficiency score was 87.44% during baseline. The post intervention mean for sleep efficiency was 88.93%. Both minimum and maximum values for sleep efficiency increased after intervention (63.39% to 72.05% and 98.59 to 99.58%). Duration of sleep intervals during baseline averaged 526.623 minutes while post-intervention measures averaged 521.26 minutes although the maximum measure for duration increased from 666 minutes during baseline to 745 minutes post-intervention. The group averaged 65.14 minutes of wake time after sleep onset during the baseline period. Averaging 58.34 minutes post-intervention, the group as a whole improved by 6.81 minutes. Both minimum and maximum measures for wake after sleep onset decreased post-intervention (from 7 to 2 minutes and from 217 to 173 minutes). Lastly, the average activity index during baseline for the group was 41.20%; the average following intervention was 42.50%. For this variable, both minimum and maximum values increased following intervention. Group mean values showed that sleep minutes, sleep efficiency, and wake minutes after sleep onset variables improved following intervention. Baseline behavior ratings during the 28-day period averaged 11.23 of the possible 16 points. The scores ranged from 7 points to 16 points. The baseline mean averaged 11.43 points. The post-intervention mean of 11.26 showed no improvement for the group 32 as a whole. The minimum value of 7 decreased to 6 during the post-intervention period increasing the range from 9 to 10 points. The daily sleep diary completed by parents produced additional information about the characteristics of those subjects who participated in the study. Of the 6 subjects, five developed an illness at some point during the study. For 4 of those subjects, average length of illness was 4.5 days for the 28-day study and included illnesses identified as an ear infection or cold/allergy. The fifth subject was documented with symptoms of illness and medication intake for 21 of the 28 days of data collection. Medications included Ibuprofen, Amoxicillin, Dimetapp, or Albuteral and included two 7-day rounds of Amoxicillin. The first round of antibiotics was prescribed for strep throat. The second round was prescribed for a chest cold. The average time to bed reported by parents for the 28 days of data collection was 9:21pm. The average time to sleep as measured by actigraphy was 9:50pm. Sleep diary documentation found that following intervention, 4 of the 6 subjects averaged earlier bedtimes. Actigraphy measures for these four subjects support these parent reports. The daily sleep diary also provided information to determine percentages of days of caffeine consumption and participation in specific activities within the hour before bedtime. Four of the six 2 nd grade subjects were reported as having consumed caffeinated drinks during the course of the study. Percentage of days with caffeine consumption per subject ranged from 15% to 81%. Percentages of days participating in specific activities within the hour of bedtime found that the participants, on average, watched television in the hour before bed 63% of the days, took a bath or shower 56% of 33 the days, read before bed 52% of the days, ate a snack or dinner in the hour before bed 25% of the days, and played with toys or games 25% of the days reported. Individual Subject Values Tables 3-8 provide descriptive statistics calculated for each subject?s sleep and behavioral measures generated over the 28-day period of data collection. Tables 9-14 show descriptive statistics for each subject?s variable measures pre and post-intervention. Table 15 shows weekly means for each subject on the 5 sleep measures. Table 16 shows a summary of sleep variable improvement for all subjects. Tables 17-22 show percentage of days meeting baseline mean per variable for each subject. The percentage of days meeting or exceeding baseline mean during the intervention period will be presented when the sleep variable showed improvement post-intervention or when no improvement was found but an increase of frequency is found post-intervention. Table 23 provides a summary of each subject?s improvement with regard to percentage of days meeting or exceeding baseline mean value post-intervention for each variable. Table 24 shows a summary of the behavior ratings and each subject?s improvement. Appendix H provides graphical displays of each student?s nightly measured sleep minutes for the 28 days of data collection. Subject 1. Subject 1, a male, while having no formal diagnosis of ADD/ADHD, is prescribed 18mg of Concerta each day. He averaged 483.44 (SD 43.640) minutes of sleep during the 28-day study (See Table 3). Table 9 shows that baseline average (6 days) for sleep minutes was 454.5. Post-intervention (19 days) average was 492.58. This shows an increase of 38.08 minutes following intervention. Both minimum and maximum values for sleep minutes increased (345 to 428 and 515 to 550). As Table 17 34 shows, subject 1 met or exceeded baseline mean for sleep minutes 16 of 19 nights (89%) compared to baseline period (67%). Efficiency mean for the month was 88.28%. Pre and post-intervention measures show an improvement for his mean efficiency value. Mean efficiency increased from 82.05% during baseline to 90.25% post intervention. Both minimum and maximum values for sleep efficiency increased following the intervention (63.39% to 79.83% and 91.09% to 95.17%). In addition, the efficiency mean met or exceeded baseline mean 89% of the days versus 67% during the baseline period Table 17). Subject 1 had an overall four-week average of 550.16 minutes for duration of sleep. Baseline mean for duration decreased from 557.5 minutes during baseline to 547.84 following intervention. Noteworthy is that while the minimum value for duration did not increase, the maximum value increased from 575 minutes to 626 minutes. Measures for minutes awake after sleep onset and activity index improved post intervention for this subject. The subject?s overall mean value for awake after sleep onset for the 4-week period was 65.72 minutes. During baseline the mean value was 101.67 minutes. Post-baseline average was 54.37 minutes. Post-intervention measures show that the subject met or exceeded the baseline average 89% of the days versus 67% during baseline. Awake minutes decreased from 50 minutes as minimum value to 24 minutes post intervention. The maximum value of 119 decreased to 58.22 after intervention. Activity index averaged 44.30% for the month. This value decreased from a mean of 53.07% during baseline to a mean of 41.54% post intervention. The percentage of meeting/exceeding baseline measures increased from 50% during baseline to 89% of the days post-intervention. 35 Referring to Table 15, long-term improvement was indicated for variables measuring sleep minutes, sleep efficiency, wake after sleep onset, and activity index. Values for these variables consistently showed improvement during post-intervention as compared to baseline, 4 th week compared to week 1 of data collection, and last week vs. baseline. Subject 1 averaged a daily behavior rating of 12.0 of 16 points during data collection, baseline, and post-intervention periods. However, average measures increased during the last week as compared to the first week of data. In addition, the scores during the last week averaged higher than the baseline mean (Table 24). The sleep diary provided additional information on life-style and activities for Subject 1. The overall average time to bed for this subject was 8:57pm during the 4-week study. The average time of sleep onset, according to actigraphic data was 9:31pm. Following the intervention, average time to bed was earlier at 8:49pm versus the 9:15pm average recorded by parents during baseline. Time of sleep onset also changed from 9:45pm to 9:26pm post-intervention. Subject 1 was one of two subjects who did not drink caffeinated beverages throughout the study. His most common activities before bed were documented as reading 67% of the 28 days, watching television 62% of the days, taking a bath/shower 29% of the days, and playing with toys/games 29% of the days. Additional activities reported accounted for less than 10% of the days (snack 10%, computer 5%). Subject 2. Subject 2, a female, averaged 385.26 (SD 76.18) minutes of sleep during the 28-day study (Table 4). Baseline average (14 days) for sleep minutes was 384.29 while post intervention was 386.31 minutes. This shows an increase of 2.1 36 minutes following intervention. When sickness was controlled, an improvement from 384.29 to 403.30 minutes was found. The minimum value for sleep minutes increased while the maximum value decreased (255 min to 270 min and 583 min to 572 min). Subject 2 met or exceeded sleep minutes baseline mean 46% (60% when sick was controlled) of the nights during the post-intervention period as compared to 36% during the baseline period. The average efficiency measure for the length of the study was 79.656%. Mean efficiency decreased from 79.91% during baseline to 79.38% post intervention. Both minimum and maximum values for efficiency decreased following the intervention (72.12 min to 72.05 min and 89.01 min to 85.93min). Subject 2 averaged 485.52 minutes (91.78 SD) for sleep duration during the 28-days of data collection. She showed an increase in average sleep duration measures following intervention. Baseline mean was 483.86 minutes versus the post intervention mean of 487.31 minutes. When sickness was controlled, the post-intervention mean measure increased to 513.30 minutes. The sleep duration baseline mean was met or exceeded 50% of the days post-intervention as compared to 43% during baseline (Table 18). The variable measuring minutes awake after sleep onset, while averaging 96.82 minutes for the entire study reflects an increase in an average of measures post-intervention. The subject?s mean value for awake after sleep onset during baseline was 92.93 minutes; post-baseline average was 101.00 minutes. Activity index for subject 2 during the study averaged 46.56%. This measure improved with a mean of 45.50% (45.53% when sick controlled) post-intervention as compared to 47.62% during baseline. In addition, the activity index baseline mean was met or exceeded 62% of the 37 post-intervention days (50% when sick days controlled) as compared to 38% established during baseline. Referring to Tables 15, long-term improvement was noted for variables measuring sleep minutes, sleep efficiency, and activity index. Values for these variables consistently showed improvement post-intervention, 4 th week mean compared to week 1 of data collection, and last week mean vs. baseline (minutes only when sickness controlled for last week vs. baseline). No improvement was found post-intervention (13.2 vs. 11.3) for measures of attention as rated by the classroom teacher (Table 24). However, the last week averaged higher scores than those during the first week of data collection (13 vs. 12.8). When sickness was controlled for, the post-intervention average decreased from 12.0 to 8.5 points and the last week?s average decreased from 13.0 to 10.0 points. No pattern of improvement was found when weekly averages were compared. Week 2 improved with an average of 13.6 but then decreased to an average of 10.5 (7.0 when sickness controlled) during the 3 rd week and then increased to average 13 points each day during the last week (10.0 when sickness controlled). Interesting is that when sickness was controlled (removed), the average of the ratings decreased suggesting that the student?s sickness may have been mistaken for increased attention during those days the parents documented as sick days (days 22-24). Sleep diary and actigraphic data documented that subject 2 went to bed at an average time of 10:43pm during the 28 days of data collection. Average time of sleep onset was 10:59pm. Time of going to bed showed improvement from 10:46pm during 38 baseline to 10:40pm post-intervention. Time to sleep improved from 11:08pm to 10:50pm following intervention. According to the sleep diary, this subject drank caffeinated beverages on 6 of 27 days. On four of these days, the drink was after 6 pm; for two of the days, the drink was between noon and 6pm. The most frequently participated activities during the last hour before bed included television watching 75% of the 28 days, book reading 68% of the days, homework 46% and listening to music 46%. Other activities included bath 29%, having a snack 21%, playing with toys/games 14%, and playing video games 3% of the days. Subject 3. Subject 3, a male, showed improvement on only one variable following intervention. Table 5 shows that the average activity index measure was 29.03% for the month of data collection. The mean activity index value decreased from 29.16% during baseline (20 days), to 28.65% in the post-intervention period (Table 11). In addition, the activity index is the only variable which met or exceeded the baseline mean with 86% of the post-intervention period as compared to 55% of the days during baseline (Table 19). During the 28-day study, subject 3 averaged 469.48 (SD 26.47) minutes of sleep each night. Baseline average for sleep minutes was 471.6 while post intervention was 463.43 minutes. Efficiency measures decreased as well. Mean efficiency decreased from 88.88 to 88.49% post intervention. Both minimum and maximum values decreased following the intervention (85.92% to 84.20% and 91.67% to 91.44%). The mean value for sleep duration decreased following intervention (530.70 min to 524.29 min). The minimum value increased from 469 to 478 minutes while the 39 maximum stayed the same (572 minutes). Mean wake minutes after sleep onset was 58.10 minutes during baseline and 60.86 minutes after intervention. Although when comparing weekly averages, his last week?s average (60.86 minutes) improved as compared to his first week?s average (63 minutes). As noted previously, subject 3 showed improvement in activity index following intervention. This improvement was also shown when the mean of the first week was compared to the last (29.22% to 28.65%) and when the mean of the last week was compared to his baseline mean (29.16% to 28.65%) suggesting long-term improvement in this variable (Table 15). With regard to the behavior rating scales, scores improved following intervention. The baseline mean shown on Table 24 was 12.55 while the intervention mean was 12.60. Both the post-intervention and last week periods averaged 12.6 versus the first week average of 12.5 and the baseline average of 12.55. The sleep diary provided additional information on life-style and activities for subject 3. The average time to bed for this subject was 9:24pm. The average time of sleep onset, according to actigraphic generated data was 9:52pm. Post-intervention measures showed an average of 9.26 pm to bed versus an average of 9:23pm during baseline. Time to sleep had a mean value of 9:48pm during baseline and 10:00pm following intervention. Subject 3 was one of two subjects who did not drink caffeinated beverages throughout the study. His most common activities before bed were documented as taking a bath/shower 100% of the days, reading 64% of the 28 days, playing on the computer 36%, watching television 18% of the days, or having a snack 21% of the days. 40 Additional activities reported accounted for less than 12% of the days (homework 11%, playing video games 7%, playing with toys/games 4%, and talking on the phone 4%). Subject 4. Subject 4, a male diagnosed with ADHD is prescribed 54 mg of Concerta each day. This subject was sick during the first 4 days of data collection. Scores will be reported both with data from those days and then with sickness controlled. Like Subject 3, he showed improvement only in his mean measure of activity index post-intervention (only when sickness was controlled). His average activity index measure for the month was 47.09% (Table 6). The mean activity index value decreased from 47.09% (44.66% when sickness controlled) during baseline (18 days) to 44.60% in the post-intervention period (Table 12). In addition, the activity index met or improved from baseline mean 57% of the post-intervention period as compared to 50% of the days during baseline (Table 20). Subject 4 averaged 467.76 (SD 48.88) minutes of sleep during the 28-day study. Baseline average for sleep minutes was 472.22 (473.93 when sick controlled) while the post intervention mean was 456.29 minutes. Both minimum and maximum values for sleep minutes decreased after baseline (371 to 335 and 574 to 504). While the mean value did not increase post-intervention, the percentage of days he met or exceeded the baseline mean during post-intervention increased slightly from 56% to 57% of the days. Efficiency measures, while averaging 85.62% for the study, showed no improvement when comparing the baseline mean of 85.84% (87.15% when sick controlled) to the post- intervention average of 85.07%. Interesting is that both minimum and maximum values increased post-intervention (65.01 to77.55 and 93.65 to 94.81). The mean value for duration for the 28 days was 550.04 minutes. The baseline mean of 553.83 minutes 41 (547.14 when sick controlled) decreased to an average of 540.29 minutes post intervention. Again both minimum and maximum values decreased following intervention. While duration did not show an increased average following intervention, his percentage of days for meeting or exceeding baseline mean increased during the post- intervention period when sickness was controlled. He met or exceeded baseline mean 71% of time as compared to 57% met during the baseline period. The wake after sleep onset variable averaged 78.76 minutes during the 4-week period. He had a mean value of 78.44 minutes of wake after sleep onset (70.50 when sick controlled) during baseline and 79.57 following intervention, although minimum and maximum values both decreased (28 to 25 minutes and 197 to 109 minutes) post- intervention. While subject 4 showed improvement in only one variable mean (activity) post- intervention, several other variables showed improvement during the last week as compared to the first week of data collection (Table 15). During the last week, sleep efficiency improved to a mean of 85.07% as compared to 82.04% during baseline. Minutes awake after sleep onset decreased to average 79.57 min during the last week of data collection as compared to 101.33 min averaged during the first week. Table 24 shows that post-intervention measures for attention as rated by the classroom teacher improved. His mean daily score during baseline was 9.50 (9.6 when sickness controlled) as compared to 9.75 post-intervention and for the last week. The sleep diary provided additional information on life-style and activities for Subject 4. The average time to bed for this subject was 8:31pm. The average time of sleep onset, according to actigraphic-generated data, was 8:52pm for the month. 42 Following intervention, time to bed, on average, changed from 8:56pm (baseline) to 8:40pm. Time to sleep went from 9:50 to 9:10pm. Subject 4 was reported to have consumed caffeine on 4 of 26 days accounted. On those days, the drinks were consumed between the hours of noon and 6pm. His most common activities before bed were documented as taking a bath/shower 89% of reported days, watching T.V. 67%, reading 59% of days, having a snack 41% of the days, and playing with toys/games 26% of the days. Additional activities reported took place less than 10% of the days (computer 4%, exercise 7%, talked on telephone 4%, played video games 4%). Subject 5. Subject 5, a female, did not initially show improvement on any of the five sleep measures post-intervention. Only when sickness was controlled (days 25-28) was improvement found. With sickness controlled, Subject 5 showed improvement in two measures for sleep quantity and quality. Sleep efficiency, while averaging 95.85% for the month (Table 7), improved from 96.47% during baseline (14 days), to 95.23 (96.71% when sick controlled) post-intervention (Table 13). She met or exceeded the baseline mean 60% of post-intervention days versus 43% during baseline (Table 21). This subject averaged 21.04 minutes of wake after sleep onset during the 28-day period. The baseline mean value was 17.86 minutes and the post-intervention mean was 24.21 minutes (17.30 minutes when sickness was controlled). She met or exceeded the baseline mean value 50% of the days during the post-intervention period as compared to 43% during baseline when sickness was controlled. Long-term improvement was indicated for both sleep efficiency and minutes measured as awake after sleep onset. When comparing the last week average (efficiency, 97.87%; awake time 16.67 minutes) to the first week (97.19%; 35.45 minutes) and the 43 baseline mean (96.47%; 17.85 minutes), the agreement between post-intervention improvement and 4 th week vs. baseline mean improvement indicate long-term improvement (Table 15). Sleep minutes, sleep duration, and the activity index sleep variables did not show improvement following baseline in terms of mean values or the consistency in meeting or exceeding the mean values (Table 21). Subject 5 averaged 465.14 minutes of sleep each night during the study. The baseline average for sleep minutes was 485.64 while post intervention was 444.64 minutes (445.10 when sick controlled). Both the minimum and maximum values measuring sleep minutes decreased post-intervention (438 to 330 minutes and 526 to 512 minutes). The mean value for sleep duration was 487.36 minutes for the study. Baseline average fell from 504.14 minutes during baseline to 470.57 minutes (464.10 when sick controlled) post-intervention. Again both minimum and maximum values for duration decreased following the intervention (445 to 348 minutes and 557 to 532 minutes). The variable measuring activity index showed no improvement as a result of intervention. The subject?s mean value for activity index for the 4-week period was 38.319%. The average baseline measure was 37.64% and the period following intervention averaged 38.03% (39.0% when sick was controlled). Table 24 shows that no improvement was found on behavior measures post-intervention. Subject 5 averaged 10.2 of the 16 possible points during baseline and 9.85 (9.0 when sickness controlled) during the post-intervention period. The average behavior score during the last week was 10.6 (10.0 when sickness held). Like Subjects 2 and 4, when sickness was controlled, behavior scores actually decreased (intervention average fell from 9.85 to 9.0 and the last week?s average fell from 10.6 to 10.0. 44 Sleep diary and actigraphic data documented that Subject 5 went to bed at an average time of 10:17pm during the 28 days of data collection. Average time to sleep was 10:54pm. An examination of bedtimes showed improvement to 10:02pm from 10:32pm. Time to sleep also improved from 10:40 during baseline to 10:23pm following intervention. This subject drank caffeinated beverages on 12 of 27 days. On 5 occasions, caffeine was consumed before noon. On four occasions, consumption took place between noon and 6pm. On six occasions, the child drank caffeinated drinks after 6pm. This subject participated in the following activities within the hour of bedtime: television watching 58% of the 28 days, bath/shower 31% of the days, book reading 27% of the days, homework 23%, and playing with toys/games 19% of the days. Other activities included snack 11%, computer 4%, and talking on the phone 4% of the days. Subject 6. Subject 6, a female, averaged 493.32 (SD 42.23) minutes of sleep during the 28-day study (Table 8). Baseline average (6 days) for sleep minutes was 501.8 while post-intervention was 491.20 minutes (Table 14). The minimum and maximum values for sleep minutes decreased following intervention (458 to 391 minutes and 593 to 563 minutes). Efficiency measures averaged 90.78% for the duration of the study. An increase in mean values was found when comparing the baseline mean of 89.77% to the post-intervention mean of 90.98%. Frequency of meeting or exceeding the baseline mean increased from 20% during baseline to 70% post-intervention (71% when sick was controlled). The average minutes of sleep duration during the study was 548.28 minutes. There was a decrease in mean minutes of sleep duration following intervention (558 to 45.85 minutes) even though the maximum measure increased from 627 to 646 minutes. 45 The mean value of the variable measuring minutes of wake time after sleep onset improved post-intervention. The month of measures averaged 51.20 minutes. The mean value for this measure decreased from 56.2 minutes during baseline to 49.95 during the post-intervention period. The percentage of meeting or exceeding baseline mean during the intervention period increased from 60% minutes during baseline to 70% during the post-intervention period. When sickness was controlled, activity index improved with a mean of 48.04 (46.26% when sick controlled) from the 47.17% average during baseline. Long-term improvement was noted for variables measuring sleep efficiency, wake minutes after sleep onset, and activity (when sick was controlled). Values for these variables consistently showed improvement when comparing post-intervention to baseline (Table 22), baseline to 4 th week of data collection, and 1 st week to the 4 th week of data collection (Table 15). Sleep diary and actigraphic data documented that subject 6 went to bed at an average time of 8:27pm during the 28 days of data collection. Average time to sleep was 8:49pm. An examination of bedtimes pre and post-intervention shows that on average, the subject went to bed at 8:20pm during baseline and 8:30pm following intervention. In addition, actigraphic data showed that the average time to sleep during baseline was 8:30pm and was 8:58pm following intervention. This subject drank caffeinated beverages regularly during the 28-day study (81% of days). She was documented as having drank caffeine equally between the 3 time periods: before noon, noon to 6pm, and after 6pm. For subject 6, the most frequently participated activities during the last hour before bed included television watching 100% 46 of the days, bath 68% of the days, homework 64% of the days, playing with toys/games 48% of the days, having a snack 32% of the days, and reading 28% of the days. Additional activities included listening to music 16% of the days, exercise 12%, playing on the computer 8%, and talking on the phone 4% of the days. 47 DISCUSSION Sleep Variable Change Referring to Table 15, results show that if a variable mean value improved post-intervention, it also showed improvement when comparing the last week and first week of data collection and when last week and baseline means were compared. In addition, variable value improvement for each subject post-intervention predicted an increase in frequency of meeting/exceeding baseline mean values post-intervention (Tables 17-23). Four variables improved for Subject 1 (minutes, efficiency, wake time after sleep onset, and activity) and Subject 4 (activity, minutes, efficiency, and duration). While Subject 4 saw mean improvement in only one variable (activity) post-intervention, this subject showed increased frequency during the post-intervention period in meeting/exceeding the baseline mean values for sleep minutes and duration of sleep intervals. This subject also showed improvement in measured efficiency during the last week as compared to the first week of data collection. Three variables showed improvement for Subjects 2 (minutes, duration, activity) and 6 (efficiency, wake time after sleep onset, activity). Two variable values improved for Subject 5 (efficiency, wake time after sleep onset) and Subject 3 (activity and wake time after sleep onset). For Subject 3, improvement for wake after sleep onset was found only when comparing the last week of data collection to the first week. 48 Referring to Table 23, activity index was the most common sleep variable to show improvement post-intervention (5 of 6 subjects). Variables measuring sleep efficiency, wake time after sleep onset, and sleep minutes improved for 3 of the 6 subjects. Sleep duration was shown to be the variable least likely to improve (increase) following intervention (1 of 6 subjects). This is interesting because as noted in the results, daily sleep diary documentation and supporting actigraphy data showed that following intervention, 4 of the 6 subjects averaged earlier bedtimes. This could indicate that sleep duration may be more reflective of a biological rhythm which is resistant to short-term changes and as a result, takes a longer period of time to reset. Table 15 shows that while 5 of the 6 subjects showed immediate variable value improvement during the week following baseline (one showed improvement on 5/5 variables, one showed improvement for 4/5 variables, and 3 showed improvement on 1/5 variables) this was only a 40% success-rate (12/30 possible improved values). The average number of sleep variable values to increase per subject was 2. The second week after intervention showed a higher improvement rate with a percentage of 65% (13 of 20 possible values improved). The average number of improved variable values was 3.2. This may be one of the reasons that Subjects 3 and 4 were shown to have the fewest number of variables showing mean value improvement post-intervention (1 of 5 variables). It could also explain why Subject 4 was the only subject to show improved frequencies for variable values post-intervention that were not also identified as variables having shown improvement post-intervention. For these subjects, intervention took place after the third week of data collection, leaving only seven days to show improvement post-intervention. For these two subjects, the activity index variable value was the only 49 variable to show improvement post-intervention although both subjects showed additional variable improvement when comparing first week and last week of data collection. Subject 3 showed improvement on two of the five variables while Subject 4 showed improvement on three of five variables. Both showed improvement on the wake minutes after sleep onset and activity index variables when comparing first and last week mean values. Long-term improvement, based on agreement between period improvement (post- intervention versus baseline mean; last week versus baseline mean), was found for all six subjects (Table16). Subject 1 showed long-term improvement on four of five sleep variables including sleep minutes, efficiency, wake time after sleep onset, and activity. Subject 2 had long-term improvement for three of five variables including minutes, duration, and activity. Subjects 3 and 4, showed long-term improvement on one variable (activity). Subject 5 evidenced long-term improvement for two of the five sleep variables including sleep efficiency and wake time after sleep onset. Subject 6 showed long-term improvement for three of five variables including efficiency, wake time after sleep onset, and activity. Long-term improvement was most often seen with activity measures (5/6 subjects). Efficiency and wake after sleep onset showed long-term improvement with three of six subjects. Minutes of sleep showed long-term improvement for two subjects; duration showed long-term improvement for only one subject. Important to note here is that Subjects 3 and 4, who had the least number of long-term sleep variable improvement, also share the same classroom and teacher. Could their daily environment or experience have been stronger than parental influence on sleep values? 50 Behavior Change Table 24 shows post-intervention improvement on behavioral measures. Post-intervention improvement occurred for two of five subjects. Two additional subjects showed improvement when comparing the first and last week of data collection. For one of those subjects, the last week?s mean value was improved over the baseline mean value as well. Due to disagreement in period improvement, only two subjects were shown to have long-term behavior variable improvement. In addition, these two subjects, Subjects 3 & 4, were found to be the only subjects whose frequency of meeting or exceeding baseline mean values for behavior increased post-intervention. An examination of behavior and sleep variable improvement did not find a relationship between improved sleep and behavior variables. With regard to sleep variable improvement, Subjects 3 and 4 showed long-term improvement on only activity measures. Three additional subjects showed long-term improvement for activity measures, yet they did not show post-intervention or long-term improvement for behavior variable mean values. As noted in the results, when sickness was controlled, two subjects? behavior scores actually decreased (measures of attention were rated higher on days these kids were reported sick and taking medication) suggesting that student activity level may influence teacher ratings of observed behaviors of attention. Comparison Between Boys and Girls A comparison of data between boys (N=3) and girls (N=3) found that over the course of this study, boys averaged 473. 45 minutes of sleep each night compared to girls who averaged 446.98 minutes (Table 25). Girls showed higher average efficiency measures (88.79%) compared to boys (87.59%). Boys showed longer average duration 51 values (542.71 minutes) compared to the girls (505.78 minutes). Boys showed more wake after sleep onset time (67.53 minute average) versus the girls who averaged 56.04 minutes. Lastly, boys showed a lower activity index average (39.63%) compared to the girls (44.05%). Thus, while boys generated higher average measures for sleep minutes and duration measures, they were more active, spent more time awake after sleep onset, and had less degree of sleep efficiency. Similar results were generated when Buckhalt, El-Sheikh, and Keller (2007), studying sleep and cognitive functioning with a sample of eight-year olds, found that girls had lower sleep activity, better sleep efficiency, and longer sleep duration than boys. With regard to intervention, short-term improvement looked only slightly different than long-term improvement for boys. Girls showed no difference between short and long-term improvement. While not showing a difference between boys and girls when comparing sleep minute variable improvement long-term, boys showed more short-term improvement (2 versus 1). Data indicated long-term improvement twice as often for girls on sleep variables measuring duration, efficiency, and wake time after sleep onset. Activity index improved for all three boys while improving for only two girls. Duration variable values did not show short or long-term improvement for boys. One female showed both short and long-term improvement in this sleep variable. Thus, while boys more often showed short-term improvement for sleep minutes, girls were found to more often improve sleep efficiency, duration, and wake after sleep onset variables as compared to the boys. Two of the three boys were found to have improved behavioral variables both short and long-term while none of the girls showed improved behavior measures. 52 Pharmacological Effects Prescription medication for ADHD did not appear to decrease a subject?s improvement in any sleep variable measure as compared to those who did not take daily medication for ADHD symptoms. Both Subject 1 and Subject 4 took prescription Concerta each day. While Subject 1 took only 18 mg and showed long-term improvement on 4 of 5 sleep variable measures, behavioral measures did not improve. In addition, this subject took several other medications throughout the month of data collection. Because illness and medication intake occurred so frequently during this study, sickness could not be controlled for Subject 1. Subject 4, the only subject to have a clinical diagnosis of ADHD and take 54 mg of Concerta each day, showed improvement on several variables. Like other subjects, immediate change was not evident in all these variables following intervention. It must be noted that this study could not rule out pharmacological effects, which could have decreased his ability to show immediate change. However, Subject 4 is one of two subjects who showed both short and long-term improvement on the behavioral measure. Limitations Potential limitations of this study include the generalizability to students outside of Grade 2. Normative values for objective measures of sleep for typically developing children are sparse and therefore the values and response to intervention found in this study could be a local or regional phenomena. In addition to the normative values generated, characteristics of children in grade 2 may be different than children in other grades. For instance, children in grade 2 may be more compliant with changes in routine or may adapt to changes more easily. 53 Other limitations to be considered include the sample size and effects of convenience sampling. The reliability of results from this study are limited. A stronger case could be made with a sample size larger than six students. In addition to the size of the sample, convenience sampling could have influenced the low response rate. Due to such a low response rate, this study had to use those who responded regardless of the degree of sleep problems reported by the parents. One of the consequences of this could be that some children did not show particularly poor sleep variable measures during baseline and because of this, there may have been a ceiling effect such that there was little room for improvement. Of those parents who did respond, the limitations of self-selection bias and parent compliance should be considered. With a 2.6% response rate, these parents may be quite different than those in the rest of the population. The parents who responded to the invitation to participate in this study may be more likely to read, participate, and comply with programs and information developed for the benefit of their child. Other personal characteristics such as strong personal beliefs about sleep practices could affect experimental outcomes as well. For instance, a parent for one subject was adamant in her belief that children should not have set bedtimes, but be allowed to sleep whenever they wished. This subject was the only student whose sleep diary documents ?naps? before going to school in the mornings. Another limitation to be considered is the length of the study. This study may not have been long enough to see change in certain variables. On the other hand, wearing the watch for 28 days could have motivated the parents to be more consistent in behaviors 54 and practices associated with their child?s sleep since the actigraphic monitor (watch) had to be placed on the children each night before going to bed. Other limitations include the possible comorbidity of undiagnosed disorders. As mentioned in the literature review, the development, regulation, and timing of sleep can be altered by behavioral/emotional disorders. Lastly, subjective teacher rating scales tend have low reliabilities and therefore need to be taken in consideration when examining the behavioral data. Conclusions Results show that the six children in this sample did not sleep the recommended 10.5 hours of sleep each night, even after intervention. Only three of the six subjects had healthy sleep when measured as obtaining a recommended 90% sleep efficiency rate. Subjects in this current 28-day study averaged a duration of 8:43 (hr:min)(SD=60.10), an activity index measure of 41.87 (SD=9.64), and an efficiency measure of 88.20 (SD = 6.88). Buckhalt, El-Sheikh, and Keller (2007) found that students identified as European-American (N=92) averaged a sleep duration measure of 8:41 (SD=35 min), an activity index of 46.44 (SD=12.23), and a sleep efficiency measure of 86.82 (SD=7.03) while African-American subjects (N=42) averaged a duration measure of 8:19 (SD=35), an activity index of 40.48, and an efficiency measure of 87.34 (SD=7.93). These were significant differences (p<.01) between races for sleep measures of activity and duration. It was hypothesized that parent behavior regarding sleep practices could positively influence child sleep measures. This studied showed that one specific practice, time putting children down, averaged earlier times post-intervention for 4 of the six subjects. Yet duration values improved for only one of those four subjects. As discussed 55 earlier, duration may be a sleep variable that takes longer to show improvement. Noteworthy is that of those children who showed an increase in sleep minutes following baseline, only two showed an increase in both minutes and duration. This indicates that duration may predict minutes, but minutes did not predict duration. Buckhalt, El-Sheikh, and Keller (2007) found only modest associations between measures of sleep quality (activity and efficiency) and sleep quantity (duration). The four subjects who averaged earlier bedtimes post intervention (Subjects 1, 2, 4, and 5) showed higher levels of sleep variable improvement. These four subjects showed an improvement in 10 out of 20 possible sleep variables versus 4 of 10 possible variables found for the remaining subjects who were not shown to average earlier bedtimes post-intervention. This suggests that while earlier bedtimes did not improve mean sleep duration measures, earlier mean bedtimes appear to have increased a child?s chances of improving other sleep variable measures. The overall efficacy of the experimental effects of the parent education program for this study is difficult to determine. While some variable values improved for subjects, not all variables were found to improve. The limitations previously mentioned may account for this and/or the intervention may not have been strong enough to influence parent behavior. This can be illustrated by the choice of intervention methods that all parents chose. This study provided parents a choice between a one-on-one PowerPoint presentation with a copy (including notes) sent home (via email or hard copy), or only the emailed program/hard copy of the presentation (notes included). All parents chose the method that did not require a one-on-one power point presentation. While results showed positive change in some variables for all subjects, it is hypothesized that more 56 improvement would have been shown had parents had both the one-on-one PowerPoint presentation and a hard copy of the presentation to take home. Still, results from this study indicate that schools may be able to expect improved sleep values in students just by sending sleep information home. While a passive approach to educating parents, this method may prove less intrusive, more convenient (no attendance, no scheduled times), as well as more cost effective and attractive to parents. School systems may not have access to a speaker and may want to know the effectiveness of just sending sleep information home. This study provides evidence of what schools could expect as long as potential limitations are considered. In addition, while experimental efficacy of this study is difficult to determine using graphical display and descriptive statistics, there is significant value in the normative data generated with regard to sleep and individual subject practices and characteristics. This is the first experimental sleep study to obtain objective measures of sleep beyond a two week period for typical, normally developing school-age children. This study provides 28-consecutive days of data collection for six children including objective sleep measures as well as parent-completed sleep diary information and teacher completed daily behavior ratings for observed student attention. The collaborative use of data from these tools provided insight to sleep variable values as well as a possible relationship between earlier average time to bed post-intervention and an increase of sleep variable improvement. From the 28-consecutive days of data collection, normative measures were generated for several sleep variables. With such a long period of data collection, several different comparisons could be made. One benefit of such an extended set of collected 57 data can be illustrated with the variable measuring sleep minutes. It was found that weekly mean values showed that all subjects stayed within 60 minutes of their previous and future week?s mean values for sleep minutes (Table 15). Yet, the range in values were much greater when examining day by day values (see Appendix H). So, while great variations in sleep measures occurred for individuals and appear to indicate unstable sleep patterns, these large variations disappeared when measures were averaged across time, revealing a more stable picture of sleep variable patterns. Implications for Future Research One challenge for future sleep research includes establishing normative values for objective sleep variables. This study provides 28 consecutive days of normative sleep values. It would be interesting to know how these children compare to their peer group in different regions of the United States and other countries. Would objective measures such as what has been provided through this study change the daily recommended amount of sleep or efficiency rate? Future sleep research should identify sleep variable relationships. For instance, in this study activity levels decreased, yet wake time after sleep onset and sleep efficiency measures did not show improvement. What accounts for the inconsistency in these values? An additional goal for future research would be to identify if a hierarchy of sleep variable change exists. For example, which if any sleep variable measure has to improve before sleep duration will show improvement? Lastly, future studies should identify objective sleep variables found most to correlate to positive change in academic functioning. Doing so could help establish more concise interventions and measures of experimental effectiveness for parent education programs. This type of research should 58 include objective behavioral measures such as systematic observations to examine behavior variables. With regard to future parent education intervention studies for sleep, it would prove valuable to follow up with post-study surveys on parent behavioral practices which could account for change found in measures. Such surveys could also identify what information parents find to be most influential on their behavioral practices. 59 REFERENCES Acebo, C., Sadeh, A., Seifer, R., Tzischinsky, O., Wolfson, A., Hafer, A., et al. (1999). Estimating sleep patterns with actigraphy monitoring in children and adolescents: How many nights are necessary for reliable measures? Sleep, 22, 95-103. Adair, R., & Bauchner, H. (1993). Sleep problems in childhood. Current Problems in Pediatrics, 23,147-170. Adair, R., Zuckerman, B., Philipp, B., Levenson, S., & Zuckerman, B. (1991). Reducing night waking in infancy: A primary care intervention. Pediatrics, 87, 500-504. Adams, L., & Rickert, V. (1989). Reducing bedtime tantrums: Comparisons between positive routines and graduated extinction. Pediatrics, 89, 756-759. American Heritage Dictionary of the English Language (3 rd edition). (1992). Boston, MA: Houghton Mifflin. Anders, T., Carskadon, M., Dement, W., & Harvey, K. (1978). Sleep habits of children and the identification of pathologically sleepy children. Child Psychiatry and Human Development, 9, 56-62. Anders, T., Sadeh, A., & Appareddy, V. (1995). Normal sleep in neonates and children. In Dahl, R. (1996). The regulation of sleep and arousal: Development and psychopathology. Development and Psychopathology, 8, 3-27. 60 Archbold, K., Pituch, K., Panahi, P., & Chervin, R. (2002). Symptoms of sleep disturbances among children at two general pediatric clinics. Journal of Pediatrics, 140, 97-102. Aserinsky, E., & Kleitman, N. (1953). Regularly occurring periods of eye mobility, and concomitant phenomena, during sleep. Science, 118, 273-274. Bee. H., & Boyd, D. (2002). Lifespan development (3 rd ed.) Boston, MA: Allyn & Bacon. Blader, J., Koplewicz, H., Abikoff, H., & Foley, C. (1997). Sleep problems of elementary school children: A community survey. Archives of Pediatrics and Adolescent Medicine, 151, 473-480. Blumberg, M., & Lucas, D. (1990). A developmental and component analysis of active sleep. Developmental Psychobiology, 29, 1-22. Bonnet, M. (1994). Sleep deprivation. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (2 nd ed., pp. 50-67). Philadelphia: Saunders. Buckhalt, J.A., El-Sheikh, M., & Keller, P. (2007). Children?s sleep and cognitive performance: Race and socioeconomic status as moderators of effects. Child Development, 78, 213-231. Busby, K., & Pivik, R. (1983). Sleep patterns in children of superior intelligence. Journal of Child Psychology and Psychiatry, 24, 587-600. Carlson, N. (1992). Foundations of physiological psychology (2 nd ed). Needham Heights, MA: Allyn and Bacon. 61 Carskadon M. (1982). The second decade. In: Guilleminalut C., (Ed.). Sleeping and waking disorders: Indications and techniques. Menlo Park, CA: Addison Wesley. Carskadon, M. (1990). Patterns of sleep and sleepiness in adolescents. Pediatrician, 17, 5-12. Christodulu, K., & Durand, M. (2004). Reducing bedtime disturbance and night waking using positive bedtime routines and sleep restriction. Focus on Autism and Other Developmental Disabilities, 19, 130-139. Chugani, H., Phelps, M., & Maziota, J. (1987) Positron emission tomography study of human brain functional development. Annals of Neurology, 22, 487-497. Cicchetti, D., & Beeghly, M. (1990). The self in transition: Infancy and childhood. In Dahl, R. (1996). The regulation of sleep and arousal. Development and Psychopathology, 8, 3-27. Cohen-Zion, M., & Ancoli-Israel, S. (2004). Sleep in children with attention-deficit hyperactivity disorder (ADHD): A review of naturalistic and stimulant intervention studies. Sleep Medicine Reviews, 8, 379-402. Dahl, R. (1996). The regulation of sleep and arousal: Development and psychopathology. Development and Psychopathology, 8, 3-27. Dahl, R., & Lewin, D. (2002). Pathways to adolescent health: Sleep regulation and behavior. Journal of Adolescent Health, 31, 175-184. 62 Dearing, E., McCartney, K., Marshall, N., & Warner, R. (2001). Parent reports of sleep and wakefulness: Longitudinal associations with cognitive and language outcomes. Infant Behavior & Development, 24, 151-170. Dinges, D., Pack, F., Williams, K., Gillen K., Powell, J., Ott, G., et al. (1997). Cumulative sleepiness, mood disturbance, and psychomotor vigilance performance decrements during a week of sleep restricted to 4-5 hours per night. Sleep, 20, 267-277. El-Sheikh, M., Buckhalt, J.A., Cummings, E., & Keller, P. (2007). Sleep disruptions and emotional insecurity are pathways of risk for children. Journal of Child Psychology and Psychiatry, 48, 88-96. Epstein, R., Chillag, N., & Lavie, P. (1998). Starting times of school: Effects on daytime functioning of fifth-grade children in Israel, Sleep, 21, 250-256. Ezzo, G. & Bucknam, R. (1995). On becoming babywise. Sisters, OR: Multnomah. Fallone, G., Acebo, C., Seifer, R., & Carskadon, M. (2005). Experimental restriction of sleep opportunity in children: Effects on teacher ratings. Sleep, 28, 1561-1567. Fallone G., Owens J., & Deane J. (2002). Sleepiness in children and adolescents: clinical implications. Sleep Medical Reviews, 6, 287-306. Fallone, G., Seifer, R., Acebo, C., & Carskadon, M. (2002). How well do school-aged children comply with imposed sleep schedules at home? Sleep, 25, 739-745. 63 Futterman, A., Lacks, P., & Wolfson, A. (1992). Effects of parent training on infant sleeping patterns, parent stress, and perceived parental competence. Journal of Consulting and Clinical Psychology, 60, 41-48. Gass, E., & Strauch, I. (1984). The development of sleep behavior between 3 and 11 years. In Proceedings of the 7 th European Sleep Congress, Munich, Germany. Gregory, A., Rijsdijk, F., & Eley, T. (2006). A twin-study of sleep difficulties in school- aged children. Child Development, 77, 1668-1679. Groome, L., Swiber, M., Atterbury, J., Bentz, L., & Holland, S. (1997). Similarities and differences in behavioral state organization during sleep periods in the perinatal infant before and after birth. Child Development, 68, 1-11. Gozal, D. (1998). Sleep disordered breathing and school performance in children. Pediatrics, 102, 616-620. Hobson, J. A. & Pace-Schott, E.F. (2002). The cognitive neuroscience of sleep: Neuronal systems, consciousness and learning. Nature Reviews Neuroscience, 3, 679-693. Kahn, A., Van de Merckt, C., Rebuffat, E., Mozin, M., Sottiaux, M., Blum, D. et al. (1989). Sleep problems in healthy preadolescents. Pediatrics, 84, 542-546. Kagan, J. (1981). The second year. Cambridge, MA: Harvard University Press. Kalat, J. (1992). Biological psychology (4 th ed.). Belmont, CA: Wadsworth Kerr, S., Jowett, S., & Smith, L. (1996). Preventing sleep problems in infancy: A randomized controlled trial. Journal of Advanced Nursing, 24, 938-942. 64 Kuhn, B., & Elliot, A. (2003). Treatment efficacy in behavioral pediatric sleep medicine Journal of Psychosomatic Medicine, 54, 587-597. Levin, H., Culhane, K., Hartmann, J., Evankovich, K., Mattson, A., Harward H., et al. (1991). Developmental changes in performance on tests of purported frontal-lobe functioning. Developmental Neuropsychology, 7, 377-395. Mindell, J. (1999). Empirically supported treatments in pediatric psychology: Bedtime refusal and night wakings in young children. Journal of Pediatric Psychology, 24, 465-481. Mindell, J., Kuhn, B., Lewin, D., Meltzer, L., & Sadeh, A. (2006). Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep, 29, 1263-1276. Mindell, J., Owens, J., & Carskadon, M. (1999). Developmental features of sleep. Child and Adolescent Psychiatric Clinics of North America, 8, 695-725. Moore, M. (1989). Disturbed attachment in children: A function in sleep disturbance, altered dream production and immune dysfunction. Not safe to sleep: Chronic sleep disturbances in anxious attachment. Journal of Child Psychotherapy, 15, 99- 111. Morrell, J. (1999). The role of cognition in infant sleep problems as assessed by a new instrument, the Maternal Cognitions About Infant Sleep Questionnaire. Journal of Child Psychology and Psychiatry and Allied Disciplines, 40, 247-258. 65 Mullane, J., & Corkum, P. (2006). Case series: Evaluation of a behavioral sleep intervention for three children with attention-deficit/hyperactivity disorder and dyssomnia. Journal of Attention Disorders, 10, 217-227. National Institutes of Health http://wwwnblbi.nih.gov/about/ncsdr/index.htm National Institutes of Health (2003). 2003 National Sleep Disorders Research Plan. Bethesda, MD: NIH. National Sleep Foundation. Sleep in America Poll (2004). Retrieved from www.sleepfoundation.org/hottoics/index.php?secid=11&id=82 on June 1, 2005. O?Brien, L., & Gozal, D. (2004). Neurocognitive dysfunction and sleep in children: from human to rodent. The Pediatric Clinics of North America, 51, 187-202. Ohayon, M., Roberts, F., Zulley, J., Smirne, S., & Priest, R. (2000). Prevalence and patterns of problematic sleep among older adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1549-1556. Olds, S. & Papalia, D. (1992). Human development (5 th ed.). New York, NY: McGraw- Hill. Owens, J., France, K., & Wiggs, L. (1999). Behavioral and cognitive-behavioral interventions for sleep disorders in infants and children: A review. Sleep Medicine Reviews, 3, 281-302. Owens, J., Spirito, A., McGuinn, M., & Nobile, C. (2000). Sleep habits and sleep disturbance in elementary school aged children. Journal of Developmental and Behavioral Pediatrics, 21, 27-36. 66 Owens, J. & Witmans, M. (2004). Sleep problems. Current Problems in Pediatric Adolescent Health Care, 34, 154-179. Owens, J., Maxim, R., & McGuin, M. (1991). Television viewing and sleep disturbance in school children. Pediatrics, 103, E27. Piazza, C., Fissher, W., & Kahng, S. (1996). Sleep patterns in children and young adults with mental retardation and severe behavior disorders. Developmental Medicine and Child Neurology, 38, 335-344. Pilcher, J., & Huffcutt, A. (1996). Effects of sleep deprivation on performance: A meta- analysis. Sleep, 19, 318-326. Pressman, M., & Orr, W. (1997). Understanding sleep: The evaluation and treatment of sleep disorders. Washington, DC: American Psychological Association. Quine, L. (1991). Sleep problems in children with mental handicap. Journal of Mental Deficiency Research, 35, 269-290. Quine, L. (1992). Severity of sleep problems in children with severe learning disabilities: Description and correlates. Journal of Community and applied Social Psychology, 2, 247-268. Randazzo, A., Muehlbach, M., Schweitzer, P., & Walsh, J. (1998). Cognitive function following acute sleep restriction in children ages 10-14. Sleep, 21, 861-868. Rapoff, M., Christophersen, E., & Rapoff, K. (1982). The management of common childhood bedtime problems by pediatric nurse practitioners. Journal of Pediatric Psychology, 7, 179-196. 67 Rechtschaffen, A., Gilliland, M., Bergmann, B., & Winter, J. (1983). Physiological correlates of prolonged sleep deprivation in rats. Science, 221, 182-184. Richman, N., Stevenson, J. & Graham, P. (1982). Preschool to school: A behavioral study. London: Academic Press. Rona, R.J., Gulliford, M.C. & Chinn, S. (1998). Disturbed sleep: Effects of sociocultural factors and illness. Archives of Disease in Childhood, 78, 20-25. Sadeh, A. (1996). Stress, trauma and sleep in children. Child and Adolescent Psychiatric Clinics of North America, 5, 685-700. Sadeh, A. & Anders, T. (1993). Infant sleep problems: Origins, assessment, intervention. Infant Mental Health Journal, 14, 17-34. Sadeh, A. & Gruber, R. (1998). Sleep disorders. In T. Ollendick (Ed.), Comprehensive clinical psychology (Vol. 5, pp. 629-653). Sadeh, A., Lavie, P., Scher, A., Tirosh, E., & Epstein, R. (1991). Actigraphic home- monitoring sleep disturbed and control infants and young children; A new method for pediatric assessment of sleep-wake patterns. Pediatrics, 87, 494-499. Sadeh, A., Raviv, A. & Gruber, R. (2000). Sleep patterns and sleep disruptions in school- age children. Developmental Psychology, 36, 291-301. Sadeh, A., Gruber, R., & Raviv, A. (2002). Sleep, neurobehavioral functioning, and behavior problems in school-age children. Child Development, 73, 405-417. 68 Sadeh, A., Gruber, R., & Raviv, A. (2003). The effects of sleep restriction and extension on school-age children: What a difference an hour makes. Child Development, 74, 444-455. Stein, M., Mendelsohn, J., Obermeyer, W., Amromin, J., & Benca, R. (2001). Sleep and behavior problems in school-age children. Pediatrics, 107, e60. Stoudemire, A. (1990). Human behavior: An introduction for medical students. Philadelphia, PA: J.B. Lippincott Company. Tankova, I., Adan, A., & Buela-Casal, G. (1994). Circadian typology and individual differences: A review. Personality and Individual Differences, 16, 671-684. Terman, L. M. (1925). Genetic studies of genius, Vol. l. Mental and physical traits of a thousand gifted children. Stanford, CA: Stanford University Press. Thoman, E. (1990). Sleeping and waking states in infants; A functional perspective. Neuroscience and Biobehavioral Review, 14, 93-107. Tikotzky, L., & Sadeh, A. (2001). Sleep patterns and sleep disruptions in kindergarten children. Journal of Clinical Child Psychology, 30, 581-591. Transforming the Federal Role in Education so that No Child is Left Behind Act (2001).U.S. Department of Education. Retrieved from http://www.ed.gov/nclb/landing.jhtml?src=pb on June, 15, 2003. Van den Bulck, J. (2004). Television viewing, computer game playing, and internet use and self-report time to bed and time out of bed in secondary-school children. Sleep, 27, 101-104. 69 Van Tassel, E. (1985). The relative influence of child and environmental characteristics on sleep disturbances in the first and second years of life. Developmental and Behavioral Pediatrics, 6, 81-86. Weissbluth, M. (1987). Healthy sleep habits, happy child. New York, NY: Ballantine Books. Welsh, M., & Pennington, B. (1988). Assessing frontal lobe functioning in children: Views from developmental psychology. Developmental Neuropsychology, 4, 199- 230. Welsh, M., Pennington, B., & Groisser, D. (1991). A normative-developmental study of executive function: A window of prefrontal function in children. Developmental Neuropsychology, 7, 131-149. Wiggs, L., & Stores, G. (1996a). Severe sleep disturbances and daytime challenging behavior in children with severe learning disabilities. Journal of Intellectual Disability Research, 40, 518-528. Wiggs, L., & Stores, G. (1996b). Sleep problems in children with severe intellectual disabilities: What help is being provided? Journal of Applied Research in Intellectual Disabilities, 9, 159-164. Wolfson, A., & Carskadon, M. (2003). Understanding adolescents? sleep patterns and school performance: A critical appraisal. Sleep Medicine Reviews, 7, 491-506. Wolfson, A., & Carskadon, M. (1998). Sleep schedules and daytime functioning in adolescents. Child Development, 69, 875-887. 70 Wolfson, A., Carskadon, M., Acebo, C., Seifer, R., Fallone, G., Labyak, S., et al. (2003). Evidence for the validity of a sleep habits survey of adolescents. Sleep, 26, 213- 216. Wolfson, A., Futterman, A., & Lacks, P. (1992). Effects of parent training on infant sleeping patterns, parents? stress, and perceived parental competence. Journal of Consulting and Clinical Psychology, 66, 41-48. Wozniak, P. (2000). Good sleep, good learning, good life. Retrieved April 13, 2003 from http://www.supermemo.com/articles/sleep.htm 71 APPENDIX A: AUBURN UNIVERSITY INSTITUTIONAL REVIEW BOARD (IRB) APPROVAL 72 73 APPENDIX B: SCHOOL PERMISSION FORMS 74 75 76 77 78 APPENDIX C: INFORMED CONSENT FORM 79 80 81 APPENDIX D: RECRUITMENT FOR PARTICIPATION 82 Concerned about your child?s sleep and want to know more about sleep in childhood? *Does your child have difficulties falling asleep or difficulties with waking in the morning? *Did you know that research has found that sleep problems have been associated with attention difficulties and behavior problems? FREE SLEEP CHECK-UP Offered through participation in dissertation research on sleep Call 887-1933 *Learn how much sleep your child gets on a nightly basis and the quality of that sleep *Learn about sleep in childhood *Learn about symptoms and characteristics of poor sleep and consequences of poor sleep *Learn about basic principles of sleep hygiene and what you can do to positively affect your child?s sleep *Learn about resources available to you Dissertation research on child sleep.Want to participate? Looking for second grade students. Participation Requirements: Child to wear sleep watch at night for 4 weeks. Parents keep a sleep log for each night the child wears sleep watch. Parents receive an individual presentation/packet on child sleep. Daily Behavior (4-question) Scale completed by teacher. 83 Name: Sex: Age: Race: Medication: Education Classification: Regular Ed Regular Ed/Sp.Ed Support Medical/Psychiatric Diagnosis: 1. How many hours does your child sleep at night? 2. Does your child wake up during the night? 3. Does your child exhibit daytime sleepiness? 4. Does your child have any academic difficulties? 5. Does your child have any behavioral difficulties? 6. Does your child have difficulty going to bed at night? 7. Does your child have any problems falling asleep? 8. Does your child have difficulty waking in the morning? 9. Does your child have a difficult temperament? 10. Does your child have attention problems/easily distracted? 84 APPENDIX E: DATA COLLECTION INSTRUMENTS 85 DAILY TEACHER QUESTIONNIARE Student: Date: Please rate from 1 to 4. 1= never, 2=sometimes, 3=almost always, and 4=always Alertness: on the watch, active 1 2 3 4 On-task: doing as assigned to do` 1 2 3 4 Focus: to center vision on 1 2 3 4 Concentration: to center attention on 1 2 3 4 86 Sleep Diary: Date: Time awake: Time to bed: Did your child feel ready for bed when they went to bed ? How many times did they wake up during last night? Were they ready to wake this morning? How difficult was it for them to wake up? Illness: Did your child experience any physical discomfort today? Mark all that apply Headache upset stomach cold/allergy muscle/joint pain Other Any medications? If so, what kind? Diet/Exercise Meal times: Breakfast_____ Lunch_____ Dinner_____ How many caffeine drinks today? Before 12 noon____Between 12-6____After 6pm____ Did your child have any vigorous physical activity that lasted at least 15 minutes today? If so, about what time? Check off any of these activities your child did in the HOUR before going to bed. _____Read a Book _____Took a Bath _____Had a snack _____Used a Computer _____Talked on the Phone _____Played with Toys/Games _____Did Homework _____Exercised/Played Sports _____Played Video Games _____Watched T.V. _____Listened to Music 87 APPENDIX F: INTERVENTION 88 89 90 91 92 APPENDIX G: STATISTICAL TABLES 93 Table 1 Group Overall Variable Data GRPMIN GRPEFF GRPDUR GRPAWAK GRPACTX GRPBEH N Valid 157 157 157 157 156 69 Missing 11 11 11 11 12 99 Mean 459.9682 88.2014 523.8917 61.6752 41.8671 11.2319 Std. Error of Mean 4.81492 .54941 4.79647 2.93726 .77203 .31048 Median 472.0000 88.8700 530.0000 57.0000 41.4300 11.0000 Mode 371.00(a) 85.93 530.00 28.00 39.30 12.00 Std. Deviation 60.33076 6.88408 60.09966 36.80374 9.64263 2.57902 Variance 3639.80026 47.39052 3611.96897 1354.51560 92.98039 6.65132 Range 338.00 36.19 397.00 215.00 46.88 10.00 Minimum 255.00 63.39 348.00 2.00 21.06 6.00 Maximum 593.00 99.58 745.00 217.00 67.94 16.00 Sum 72215.00 13847.62 82251.00 9683.00 6531.27 775.00 GRPMIN = Group Minutes GRPEFF = Group Efficiency GRPDUR = Group Duration GRPAWAK = Group Wake Minutes After Sleep Onset GRPACTX = Group Activity Index GRPBEH = Group Behavior Ratings 94 Table 2 Group Pre and Post-Intervention Variable Data N Range Minimum Maximum Mean Std. Deviation GRPMINBA 77 338.00 255.00 593.00 459.0519 60.83409 GRPMININ 80 302.00 270.00 572.00 460.8500 60.21293 GRPEFFBA 77 35.20 63.39 98.59 87.4443 7.14458 GRPEFFIN 80 27.53 72.05 99.58 88.9301 6.58622 GRPDURBA 77 303.00 363.00 666.00 526.6234 54.50882 GRPDURIN 80 397.00 348.00 745.00 521.2625 65.26746 GRPAWABA 77 210.00 7.00 217.00 65.1429 37.80759 GRPAWAIN 80 171.00 2.00 173.00 58.3375 35.72963 GRPACTBA 76 40.64 21.06 61.70 41.1963 10.14839 GRPACTIN 80 42.84 25.10 67.94 42.5044 9.15482 GRPBEHBA 44 9.00 7.00 16.00 11.4318 2.60052 GRPBEHIN 30 10.00 6.00 16.00 11.1333 2.52891 Valid N (listwise) 18 GRPMINBA = Group Minutes Baseline Period GRPMININ = Group Minutes Intervention Period GRPEFFBA = Group Efficiency Baseline Period GRPEFFINT = Group Efficiency Intervention Period GRPDURBA = Group Duration Baseline Period GRPDURIN = Group Duration Intervention Period GRPAWABA = Group Wake Minutes After Sleep Onset Baseline Period GRPAWAIN = Group Wake Minutes After Sleep Onset Intervention Period GRPACTBA = Group Activity Index Baseline Period GRPACTIN = Group Activity Index Intervention Period GRPBEHBA = Group Behavior Ratings Baseline Period GRPBEHIN = Group Behavior Ratings Intervention Period 95 Table 3 Subject 1 Variable Data SLEEPMI 1 SLEEPEF 1 SLEEPDU 1 WAKEMI 1 ACTIVIT 1 BEHAVIO 1 Valid 25 25 25 25 25 10 N Missing 4 4 4 4 4 19 Mean 483.4400 88.2820 550.1600 65.7200 44.3044 12.0000 Median 484.0000 89.8100 548.0000 54.0000 41.5300 12.5000 Mode 473.00 63.39(a) 452.00(a) 28.00(a) 39.30 9.00 Std. Deviation 43.63970 7.04324 39.16172 42.20142 9.26954 2.40370 Variance 1904.423 33 49.60728 1533.6400 0 1780.960 00 85.92439 5.77778 Range 205.00 31.78 174.00 193.00 29.65 6.00 Minimum 345.00 63.39 452.00 24.00 28.57 9.00 Maximum 550.00 95.17 626.00 217.00 58.22 15.00 Sum 12086.00 2207.05 13754.00 1643.00 1107.61 120.00 SLEEPMI = Sleep Minutes SLEEPEF = Sleep Efficiency SLEEPDU = Sleep Duration WAKEMI = Wake Minutes After Sleep Onset ACTIVIT = Activity Index BEHAVIO = Behavior Rating 96 Table 4 Subject 2 Variable Data SLEEPMI 2 SLEEPEF 2 SLEEPDU 2 AWAKEMI 2 ACTIVIT 2 BEHAVIO 2 Valid 27 27 27 27 26 17 N Missing 2 2 2 2 3 12 Mean 385.2593 79.6563 485.5185 96.8148 46.5604 12.4118 Median 372.0000 78.7700 451.0000 87.0000 48.1550 13.0000 Mode 255.00(a) 74.94(a) 451.00(a) 57.00(a) 33.19(a) 13.00 Std. Deviation 76.18328 5.11569 91.78251 32.70502 6.69512 3.29884 Variance 5803.891 74 26.17029 8424.0284 9 1069.6182 3 44.82467 10.88235 Range 328.00 16.96 388.00 116.00 25.39 10.00 Minimum 255.00 72.05 357.00 57.00 33.19 6.00 Maximum 583.00 89.01 745.00 173.00 58.58 16.00 Sum 10402.00 2150.72 13109.00 2614.00 1210.57 211.00 SLEEPMI = Sleep Minutes SLEEPEF = Sleep Efficiency SLEEPDU = Sleep Duration WAKEMI = Wake Minutes After Sleep Onset ACTIVIT = Activity Index BEHAVIO = Behavior Rating 97 Table 5 Subject 3 Variable Data SLEEPMI 3 SLEEPEF 3 SLEEPDU 3 AWAKEMI 3 ACTIVIT 3 BEHAVIO 3 Valid 27 27 27 27 27 16 N Missing 2 2 2 2 2 13 Mean 469.4815 88.7793 529.0370 58.8148 29.0300 12.5625 Median 471.0000 88.7300 533.0000 56.0000 28.4500 13.0000 Mode 441.00 84.20(a) 521.00(a) 50.00 21.06(a) 14.00 Std. Deviation 26.47404 2.16442 30.97950 13.05915 3.42709 1.67207 Variance 700.8746 4 4.68472 959.72934 170.54131 11.74492 2.79583 Range 102.00 7.47 103.00 48.00 18.30 4.00 Minimum 413.00 84.20 469.00 40.00 21.06 10.00 Maximum 515.00 91.67 572.00 88.00 39.36 14.00 Sum 12676.00 2397.04 14284.00 1588.00 783.81 201.00 SLEEPMI = Sleep Minutes SLEEPEF = Sleep Efficiency SLEEPDU = Sleep Duration WAKEMI = Wake Minutes After Sleep Onset ACTIVIT = Activity Index BEHAVIO = Behavior Rating 98 Table 6 Subject 4 Variable Data SLEEPMI 4 SLEEPEF 4 SLEEPDU 4 AWAKEMI 4 ACTIVIT 4 BEHAVIO 4 Valid 25 25 25 25 25 16 N Missing 4 4 4 4 4 13 Mean 467.7600 85.6208 550.0400 78.7600 46.3880 9.6875 Median 475.0000 86.0800 563.0000 81.0000 44.6800 9.0000 Mode 490.00 86.19 432.00(a) 88.00 31.75(a) 9.00 Std. Deviation 48.88616 5.93383 50.39302 33.27321 7.61147 1.62147 Variance 2389.856 67 35.21033 2539.4566 7 1107.1066 7 57.93444 2.62917 Range 239.00 29.80 234.00 172.00 29.95 5.00 Minimum 335.00 65.01 432.00 25.00 31.75 7.00 Maximum 574.00 94.81 666.00 197.00 61.70 12.00 Sum 11694.00 2140.52 13751.00 1969.00 1159.70 155.00 SLEEPMI = Sleep Minutes SLEEPEF = Sleep Efficiency SLEEPDU = Sleep Duration WAKEMI = Wake Minutes After Sleep Onset ACTIVIT = Activity Index BEHAVIO = Behavior Rating 99 Table 7 Subject 5 Variable Data SLEEPMI 5 SLEEPEF 5 SLEEPDU 5 AWAKEMI 5 ACTIVIT 5 BEHAVIO 5 Valid 28 28 28 28 28 17 N Missing 1 1 1 1 1 12 Mean 465.1429 95.8511 487.3571 21.0357 38.3189 10.0588 Median 471.5000 95.9900 497.0000 19.5000 37.0300 10.0000 Mode 463.00 86.54(a) 477.00(a) 7.00(a) 27.56(a) 8.00 Std. Deviation 45.47015 2.78274 45.81219 14.44654 5.98466 1.88648 Variance 2067.534 39 7.74365 2098.7566 1 208.70238 35.81611 3.55882 Range 196.00 13.04 209.00 68.00 21.45 5.00 Minimum 330.00 86.54 348.00 2.00 27.56 8.00 Maximum 526.00 99.58 557.00 70.00 49.01 13.00 Sum 13024.00 2683.83 13646.00 589.00 1072.93 171.00 SLEEPMI = Sleep Minutes SLEEPEF = Sleep Efficiency SLEEPDU = Sleep Duration WAKEMI = Wake Minutes After Sleep Onset ACTIVIT = Activity Index BEHAVIO = Behavior Rating 100 Table 8 Subject 6 Variable Data SLEEPMI6 SLEEPEF6 SLEEPDU6 AWAKEMI6 ACTIVIT6 Valid 25 25 25 25 25 N Missing 4 4 4 4 4 Mean 493.3200 90.7384 548.2800 51.2000 47.8660 Median 487.0000 90.7600 536.0000 49.0000 48.6600 Mode 484.00(a) 79.19(a) 530.00 48.00(a) 30.94(a) Std. Deviation 42.23320 4.07951 39.79585 24.02950 8.24777 Variance 1783.6433 3 16.64244 1583.71000 577.41667 68.02569 Range 202.00 18.76 164.00 113.00 37.00 Minimum 391.00 79.19 482.00 10.00 30.94 Maximum 593.00 97.95 646.00 123.00 67.94 Sum 12333.00 2268.46 13707.00 1280.00 1196.65 SLEEPMI = Sleep Minutes SLEEPEF = Sleep Efficiency SLEEPDU = Sleep Duration WAKEMI = Wake Minutes After Sleep Onset ACTIVIT = Activity Index BEHAVIO = Behavior Rating 101 Table 9 Subject 1 Baseline & Intervention Variable Data N Range Minimum Maximu m Mean Std. Deviation Variance MIN1BASE 6 170.00 345.00 515.00 454.5000 60.02583 3603.100 MIN1INTE 19 122.00 428.00 550.00 492.5789 34.22039 1171.035 EFF1BASE 6 27.70 63.39 91.09 82.0483 9.80446 96.127 EFF1INTE 19 15.34 79.83 95.17 90.2505 4.73263 22.398 DUR1BASE 6 46.00 529.00 575.00 557.5000 16.93222 286.700 DUR1INTE 19 174.00 452.00 626.00 547.8421 44.06342 1941.585 AWAKE1BA 6 167.00 50.00 217.00 101.6667 59.71823 3566.267 AWAK1INT 19 95.00 24.00 119.00 54.3684 28.58751 817.246 ACTIV1BA 6 11.33 46.89 58.22 53.0667 4.66093 21.724 ACTIV1IN 19 28.81 28.57 57.38 41.5374 8.65200 74.857 BEHBASE 3 6.00 9.00 15.00 12.0000 3.00000 9.000 BEHINTER 7 6.00 9.00 15.00 12.0000 2.38048 5.667 Valid N (listwise) 1 MIN1BASE = Sleep Minutes Baseline Period MIN1INTE = Sleep Minutes Intervention Period EFF1BASE = Sleep Efficiency Baseline Period EFF1INTE = Sleep Efficiency Intervention Period DUR1BASE = Sleep Duration Baseline Period DUR1INTE = Sleep Duration Intervention Period AWAKE1BA = Wake Time After Sleep Onset Baseline Period AWAK1INT = Wake Time After Sleep Onset Intervention Period ACTI1BA = Activity Index Baseline Period ACTIV1IN = Activity Index Intervention Period BEHBASE = Behavior Rating Baseline Period BEHINTER =Behavior Rating Intervention Period 102 Table 10 Subject 2 Baseline & Intervention Variable Data N Range Minimum Maximu m Mean Std. Deviation Variance MIN2BASE 14 328.00 255.00 583.00 384.2857 82.15785 6749.912 MIN2INTE 13 302.00 270.00 572.00 386.3077 72.52860 5260.397 EFF2BASE 14 16.89 72.12 89.01 79.9143 5.38620 29.011 EFF2INTE 13 13.88 72.05 85.93 79.3785 5.01121 25.112 AWAK2BAS 14 81.00 57.00 138.00 92.9286 27.48276 755.302 AWAK2INT 13 116.00 57.00 173.00 101.0000 38.24483 1462.667 DUR2BASE 14 292.00 363.00 655.00 483.8571 85.01209 7227.055 DUR2INTE 13 388.00 357.00 745.00 487.3077 102.05912 10416.06 4 ACTIV2BA 13 17.50 36.99 54.49 47.6200 5.70682 32.568 ACTIV2IN 13 25.39 33.19 58.58 45.5008 7.64095 58.384 BEH2BASE 10 9.00 7.00 16.00 13.2000 2.89828 8.400 BEH2INTE 7 10.00 6.00 16.00 11.2857 3.72891 13.905 Valid N (listwise) 5 MIN2BASE = Sleep Minutes Baseline Period MIN2INTE = Sleep Minutes Intervention Period EFF2BASE = Sleep Efficiency Baseline Period EFF2INTE = Sleep Efficiency Intervention Period DUR2BASE = Sleep Duration Baseline Period DUR2INTE = Sleep Duration Intervention Period AWAKE2BA = Wake Time After Sleep Onset Baseline Period AWAK2INT = Wake Time After Sleep Onset Intervention Period ACTI2BA = Activity Index Baseline Period ACTIV2IN = Activity Index Intervention Period BEH2BASE = Behavior Rating Baseline Period BEH2INTE=Behavior Rating Intervention Period 103 Table 11 Subject 3 Baseline & Intervention Variable Data N Range Minimum Maximu m Mean Std. Deviation Variance MIN3BASE 20 102.00 413.00 515.00 471.6000 27.35036 748.042 MIN3INTE 7 68.00 437.00 505.00 463.4286 24.71071 610.619 EFF3BASE 20 5.75 85.92 91.67 88.8800 1.96320 3.854 EFF3INTE 7 7.24 84.20 91.44 88.4914 2.82227 7.965 DUR3BASE 20 103.00 469.00 572.00 530.7000 30.34382 920.747 DUR3INTE 7 94.00 478.00 572.00 524.2857 34.75013 1207.571 AWAK3BAS 20 39.00 40.00 79.00 58.1000 11.60717 134.726 AWAK3INT 7 47.00 41.00 88.00 60.8571 17.48741 305.810 ACTIV3BA 20 18.30 21.06 39.36 29.1615 3.56318 12.696 ACTIV3IN 7 10.24 25.10 35.34 28.6543 3.23535 10.467 BEH3BASE 11 4.00 10.00 14.00 12.5455 1.75292 3.073 BEH3INTE 5 4.00 10.00 14.00 12.6000 1.67332 2.800 Valid N (listwise) 5 MIN3BASE = Sleep Minutes Baseline Period MIN3INTE = Sleep Minutes Intervention Period EFF3BASE = Sleep Efficiency Baseline Period EFF3INTE = Sleep Efficiency Intervention Period DUR3BASE = Sleep Duration Baseline Period DUR3INTE = Sleep Duration Intervention Period AWAKE3BA = Wake Time After Sleep Onset Baseline Period AWAK3INT = Wake Time After Sleep Onset Intervention Period ACTIV3BA = Activity Index Baseline Period ACTIV3IN = Activity Index Intervention Period BEH3BASE = Behavior Rating Baseline Period BEH3INTE=Behavior Rating Intervention Period 104 Table 12 Subject 4 Baseline & Intervention Variable Data N Range Minimum Maximu m Mean Std. Deviation Variance MIN4BASE 18 203.00 371.00 574.00 472.2222 46.22013 2136.301 MIN4INTE 7 169.00 335.00 504.00 456.2857 57.38674 3293.238 EFF4BASE 18 28.64 65.01 93.65 85.8361 6.23847 38.918 EFF4INTE 7 17.26 77.55 94.81 85.0671 5.48413 30.076 DUR4BASE 18 225.00 441.00 666.00 553.8333 47.20450 2228.265 DUR4INTE 7 160.00 432.00 592.00 540.2857 60.74733 3690.238 AWAK4BAS 18 169.00 28.00 197.00 78.4444 36.10479 1303.556 AWAK4INT 7 84.00 25.00 109.00 79.5714 27.09156 733.952 ACTIV4BA 18 29.95 31.75 61.70 47.0850 8.33448 69.463 ACTIV4IN 7 14.74 37.16 51.90 44.5957 5.45156 29.719 BEH4BASE 10 5.00 7.00 12.00 9.5000 1.84089 3.389 BEH4INTE 4 2.00 9.00 11.00 9.7500 .95743 .917 Valid N (listwise) 3 MIN4BASE = Sleep Minutes Baseline Period MIN4INTE = Sleep Minutes Intervention Period EFF4BASE = Sleep Efficiency Baseline Period EFF4INTE = Sleep Efficiency Intervention Period DUR4BASE = Sleep Duration Baseline Period DUR4INTE = Sleep Duration Intervention Period AWAKE4BA = Wake Time After Sleep Onset Baseline Period AWAK4INT = Wake Time After Sleep Onset Intervention Period ACTI4BA = Activity Index Baseline Period ACTIV4IN = Activity Index Intervention Period BEH4BASE = Behavior Rating Baseline Period BEH4INTE =Behavior Rating Intervention Period 105 Table 13 Subject 5 Baseline & Intervention Variable Data N Range Minimum Maximum Mean Std. Deviation Variance MIN5BASE 14 88.00 438.00 526.00 485.6429 26.24033 688.555 MIN5INTE 14 182.00 330.00 512.00 444.6429 51.96538 2700.401 EFF5BASE 14 4.16 94.43 98.59 96.4714 1.36442 1.862 EFF5INTE 14 13.04 86.54 99.58 95.2307 3.65957 13.392 DUR5BASE 14 112.00 445.00 557.00 504.1429 28.11476 790.440 DUR5INTE 14 184.00 348.00 532.00 470.5714 54.42103 2961.648 AWAK5BAS 14 24.00 7.00 31.00 17.8571 7.28388 53.055 AWAK5INT 14 68.00 2.00 70.00 24.2143 18.93787 358.643 ACTIV5BA 14 18.41 30.60 49.01 37.6421 5.46322 29.847 ACTIV5IN 14 20.19 27.56 47.75 38.9957 6.59954 43.554 BEH5BASE 10 5.00 8.00 13.00 10.2000 2.04396 4.178 BEH5INTE 7 4.00 8.00 12.00 9.8571 1.77281 3.143 Valid N (listwise) 7 MIN5BASE = Sleep Minutes Baseline Period MIN5INTE = Sleep Minutes Intervention Period EFF5BASE = Sleep Efficiency Baseline Period EFF5INTE = Sleep Efficiency Intervention Period DUR5BASE = Sleep Duration Baseline Period DUR5INTE = Sleep Duration Intervention Period AWAK5BA = Wake Time After Sleep Onset Baseline Period AWAK5INT = Wake Time After Sleep Onset Intervention Period ACTI5BA = Activity Index Baseline Period ACTIV5IN = Activity Index Intervention Period BEH5BASE = Behavior Rating Baseline Period BEH5INTE =Behavior Rating Intervention Period 106 Table 14 Subject 6 Baseline & Intervention Variable Data N Range Minimum Maximu m Mean Std. Deviation Variance MIN6BASE 5 135.00 458.00 593.00 501.8000 55.50405 3080.700 MIN6INTE 20 172.00 391.00 563.00 491.2000 39.75928 1580.800 EFF6BASE 5 8.65 85.93 94.58 89.7740 3.09498 9.579 EFF6INTE 20 18.76 79.19 97.95 90.9795 4.32429 18.699 DUR6BASE 5 109.00 518.00 627.00 558.0000 44.14182 1948.500 DUR6INTE 20 164.00 482.00 646.00 545.8500 39.48654 1559.187 AWAK6BAS 5 41.00 34.00 75.00 56.2000 14.85598 220.700 AWAK6INT 20 113.00 10.00 123.00 49.9500 25.97463 674.682 ACTIV6BA 5 17.24 37.80 55.04 47.1420 6.29087 39.575 ACTIV6IN 20 37.00 30.94 67.94 48.0470 8.79904 77.423 Valid N (listwise) 4 MIN6BASE = Sleep Minutes Baseline Period MIN6INTE = Sleep Minutes Intervention Period EFF6BASE = Sleep Efficiency Baseline Period EFF6INTE = Sleep Efficiency Intervention Period DUR6BASE = Sleep Duration Baseline Period DUR6INTE = Sleep Duration Intervention Period AWAK6BA = Wake Time After Sleep Onset Baseline Period AWAK6INT = Wake Time After Sleep Onset Intervention Period ACTI6BAS= Activity Index Baseline Period ACTIV6INT = Activity Index Intervention Period BEH6BA = Behavior Rating Baseline Period BEH6IN=Behavior Rating Intervention Period 107 Table 15 Individual Subject Weekly Mean Values by Variable Sub1 Week 1* Week 2 Week 3 Week 4 Avg Min 454 510.57 484.40 480.43* Avg Eff 81.71 89.92 87.47 92.57 * Avg Dur 557.5 568.14 559.20 519.43 Avg Awak 101.67 57.55 71.00 39.00 * Avg ActIn 53.07 42.82 48.19 36.58 * Sub 2 Week 1 Week 2* Week 3 Week 4 (Wk 4 sick control) Avg Min 375.43 396.00 395.50 378.43* 415 *+ Avg Eff 78.54 81.29 81.26 78.30 74.72 Avg Dur 479.43 488.29 489.33 485.57* 549.25*+ Avg Awak 102.00 83.86 93.83 107.14 135.25 Avg ActIn 51.05 45.01 45.66 45.36 * 45.35 *+ Sub 3 Week 1 Week 2 Week 3* Week 4 Avg Min 485.14 462.17 466.14 463.43 Avg Eff 88.52 90.20 88.11 88.49 Avg Dur 548.14 512.33 529.00 524.29 Avg Awak 63.00 50.17 62.86 60.86 * Avg ActIn 29.22 29.28 29.00 28.65 * Sub 4 Week 1 sick Week 2 Week 3* Week 4 Avg Min 469.33 475.5 453.14 502.40 456.29 Avg Eff 82.04 83.67 87.40 88.20 85.07 * Avg Dur 575.17 571 519.43 576.40 540.29 Avg Awak 101.33 91.5 66.29 68.00 79.57 * Avg ActIn 55.88 56.49 44.18 40.59 44.60 *+ Sub 5 Week 1 Week 2* Week 3 Week 4 (Wk 4 sick control) Avg Min 479.71 491.57 440.00 444.64 457 Avg Eff 97.19 95.76 96.21 94.87 97.87 *+ Avg Dur 494.86 513.43 458.43 470.57 477.33 Avg Awak 13.86 21.86 17.57 24.21 16.67 + Avg ActIn 35.45 39.84 37.42 39.00 39.47 Sub 6 Week 1* Week 2 Week 3 Week 4 Avg Min 501.8 486.67 516.14 483.43 Avg Eff 89.77 88.78 90.89 92.96 *+ Avg Dur 558 549.17 568.57 520.29 Avg Awak 56.20 62.33 52.43 36.86 *+ Avg ActIn 47.14 53.51 49.73 40.97 *+ * Intervention Week Bold = Baseline Improvement * = 4 th week Improvement vs. 1 st week += Improvement when sickness controlled 108 Table 16 Sleep Variable Improvement by Period Subject Post-Intervention Last Week vs. Baseline Last Week vs. First Week 1 Min, Eff, Awak, Act Min, Eff, Awak, Act Min, Eff, Awak, Act 2 Min, Dur, Act Min*, Dur, Act Min, Dur, Act 3 Act Act Awak, Act 4 Act Act Eff, Awak, Act 5 Eff*, Awak* Eff*, Awak* Eff*, Awak 6 Eff, Awak, Act* Eff, Awak, Act Eff, Awak, Act Long-Term Improvement (Improvement found both when Post-Intervention>Baseline & 4 th Week> Baseline) Sub1: Min, Eff, Awak, Activity 4/5 Sub2: Min*, Dur, Activity 3/5 Sub 3: Activity 1/5 Sub 4: Activity 1/5 Sub 5: Efficiency*, Awake* 2/5 Sub 6: Eff, Awak, Activity* 3/5 *(When sickness was controlled for and a difference was found) 109 Table 17 Subject 1 Improvement Over Baseline Analysis Minutes Efficiency Duration AwakeMin Activity Day 345.00 63.39 562.00 217.00 57.12 1 488.00 84.87 575.00 87.00 50.78 2 437.00 80.04 546.00 109.00 46.89 3 485.00 86.51 566.00 75.00 56.01 4 515.00 91.09 567.00 50.00 49.38 5 . . . . . 6 457.00 86.39 529.00 72.00 58.22 7 454.5 82.04 557.5 101.67 53.07 AVG 67% 67% 67% 67% 50% 540.00 94.74 570.00 30.00 39.30 8 460.00 84.71 543.00 83.00 51.20 9 508.00 85.38 595.00 87.00 52.61 10 550.00 87.86 626.00 76.00 39.14 11 548.00 93.68 585.00 37.00 40.17 12 475.00 92.59 513.00 38.00 30.18 13 493.00 90.46 545.00 52.00 39.30 14 509.00 94.79 537.00 28.00 41.53 15 477.00 79.83 610.00 119.00 57.38 16 514.00 86.97 591.00 77.00 44.33 17 453.00 81.47 556.00 103.00 56.65 18 . . . . . 19 . . . . . 20 469.00 94.27 502.00 28.00 41.40 21 484.00 93.80 516.00 32.00 31.59 22 487.00 88.87 548.00 61.00 50.18 23 473.00 92.38 512.00 39.00 41.02 24 428.00 94.69 452.00 24.00 35.84 25 542.00 93.29 581.00 39.00 37.69 26 473.00 95.17 497.00 26.00 28.57 27 476.00 89.81 530.00 54.00 31.13 28 . . . . . 17/19 17/19 7/19 17/19 17/19 89% 89% 37% 89% 89% Bold=Improvement Over Baseline Mean Blue indicates percentage of days met or exceeded baseline mean value 110 Table 18 Subject 2 Improvement Over Baseline Analysis Minutes Efficiency Duration AwakeMin Activity Day 341.00 84.32 429.00 66.00 52.68 1 314.00 74.94 419.00 105.00 52.98 2 366.00 86.52 423.00 57.00 49.88 3 480.00 78.16 614.00 133.00 48.86 4 448.00 78.77 573.00 114.00 48.69 5 302.00 74.94 403.00 101.00 6 357.00 72.12 495.00 138.00 50.91 7 352.00 81.18 457.00 67.00 54.49 8 372.00 82.48 451.00 79.00 41.46 9 373.00 83.07 449.00 76.00 40.76 10 583.00 89.01 655.00 72.00 40.92 11 419.00 76.04 551.00 132.00 47.55 12 255.00 72.29 363.00 87.00 52.89 13 418.00 84.96 492.00 74.00 36.99 14 384.29 79.91 483.86 92.92 47.62 AVG 36% 50% 43% 57% 38% 317.00 83.86 378.00 61.00 36.77 15 403.00 85.74 470.00 67.00 33.19 16 426.00 80.53 529.00 103.00 50.28 17 427.00 75.58 565.00 138.00 58.58 18 422.00 76.73 550.00 128.00 56.18 19 378.00 85.14 444.00 66.00 38.96 20 . . . . . 21 270.00 75.63 357.00 87.00 47.62 22 371.00 84.32 440.00 69.00 43.86 23 348.00 85.93 405.00 57.00 44.69 24 333.00 74.00 450.00 117.00 49.78 25 397.00 72.05 551.00 154.00 50.27 26 572.00 76.78 745.00 173.00 44.30 27 358.00 75.63 451.00 93.00 37.03 28 6/13 6/13 5/13 6/13 8/13 46% 60% 46% 40% 38% 50% 46% 30% 62% 50% Sick days 22-24 Bold=Improvement Over Baseline Mean Blue indicates percentage of days met or exceeded baseline mean value (red=percentage of days meeting/exceeding baseline with sick days controlled for) 111 Table 19 Subject 3 Improvement Over Baseline Analysis Minutes Efficiency Duration AwakeMin Activity Day 504.00 88.73 568.00 64.00 32.39 1 482.00 85.92 561.00 79.00 26.92 2 471.00 87.55 538.00 67.00 30.48 3 475.00 90.48 525.00 50.00 30.67 4 515.00 90.19 571.00 56.00 27.50 5 464.00 85.93 540.00 76.00 29.81 6 485.00 90.82 534.00 49.00 26.78 7 450.00 90.18 499.00 49.00 27.86 8 437.00 86.71 504.00 47.00 29.56 9 499.00 90.89 549.00 50.00 27.32 10 . . . . . 11 470.00 90.21 521.00 51.00 33.78 12 477.00 91.55 521.00 44.00 30.52 13 440.00 91.67 480.00 40.00 26.67 14 441.00 86.98 507.00 66.00 28.60 15 441.00 87.67 503.00 62.00 39.36 16 480.00 86.64 554.00 74.00 30.14 17 483.00 90.62 533.00 50.00 28.14 18 497.00 86.89 572.00 75.00 29.02 19 413.00 88.06 469.00 56.00 26.65 20 508.00 89.91 565.00 57.00 21.06 21 471.6 88.88 530.70 58.10 29.16 AVG 55% 50% 55% 60% 55% 479.00 88.05 544.00 65.00 27.39 22 441.00 85.63 515.00 74.00 35.34 23 470.00 91.44 514.00 44.00 25.10 24 437.00 91.42 478.00 41.00 28.45 25 505.00 88.29 572.00 67.00 27.10 26 443.00 90.41 490.00 47.00 27.76 27 469.00 84.20 557.00 88.00 29.44 28 2/7 3/7 3/7 3/7 6/7 29% 43% 43% 43% 86% No sickness Bold=Improvement Over Baseline Mean Blue indicates percentage of days met or exceeded baseline mean value 112 Table 20 Subject 4 Improvement Over Baseline Analysis Minutes Efficiency Duration AwakeMin Activity Day 371.00 65.01 577.00 197.00 61.70 1 453.00 82.82 547.00 94.00 51.01 2 506.00 86.08 597.00 81.00 59.46 3 535.00 90.99 588.00 53.00 50.17 4 . . . . . 5 490.00 85.66 572.00 82.00 54.37 6 461.00 81.67 570.00 101.00 58.60 7 507.00 88.79 571.00 64.00 48.16 8 481.00 91.44 526.00 45.00 44.68 9 460.00 82.88 555.00 95.00 40.36 10 452.00 83.70 540.00 88.00 51.85 11 436.00 84.50 516.00 80.00 50.39 12 423.00 86.86 487.00 64.00 42.09 13 413.00 93.65 441.00 28.00 31.75 14 487.00 86.19 565.00 78.00 41.95 15 475.00 90.65 524.00 49.00 35.31 16 490.00 91.65 564.00 44.00 39.89 17 . . . . . 18 574.00 86.19 666.00 92.00 44.59 19 . . . . . 20 486.00 86.32 563.00 77.00 41.20 21 472.22 85.83 553.83 78.44 47.09 AVG 473.93 87.15 547.14 70.5 44.65 (sick controlled) 56% 57% 61% 36% 61% 57% 50% 43% 50% 57% 504.00 85.14 592.00 88.00 37.16 22 491.00 87.52 591.00 69.00 41.29 23 473.00 85.38 554.00 81.00 40.43 24 335.00 77.55 432.00 97.00 48.38 25 444.00 80.29 553.00 109.00 51.90 26 490.00 84.78 578.00 88.00 49.65 27 457.00 94.81 482.00 25.00 43.36 28 4/7 2/7 4/7 2/7 4/7 57% 43% 29% 57% 71% 29% 57% Sick days 1-4 Bold=Improvement Over Baseline Mean Blue indicates percentage of days met or exceeded baseline mean value (red=percentage of days meeting/exceeding baseline with sick days controlled for) 113 Table 21 Subject 5 Improvement Over Baseline Analysis Minutes Efficiency Duration Awake Activity Day 491.00 98.59 498.00 7.00 32.13 1 489.00 97.80 500.00 11.00 30.60 2 463.00 96.60 488.00 16.00 33.20 3 499.00 95.96 520.00 21.00 37.31 4 454.00 95.18 477.00 23.00 40.25 5 438.00 98.43 445.00 7.00 33.03 6 524.00 97.76 536.00 12.00 41.60 7 526.00 94.43 557.00 31.00 49.01 8 492.00 95.53 515.00 23.00 32.82 9 472.00 95.93 492.00 20.00 35.98 10 481.00 94.50 509.00 28.00 44.99 11 458.00 96.02 477.00 19.00 37.32 12 504.00 96.37 523.00 19.00 35.56 13 508.00 97.50 521.00 13.00 43.19 14 485.64 96.47 504.14 17.86 37.64 AVG 57% 43% 50% 43% 64% 465.00 94.32 493.00 28.00 35.09 15 330.00 94.83 348.00 18.00 31.32 16 462.00 99.35 465.00 3.00 32.90 17 483.00 95.08 508.00 25.00 27.56 18 476.00 92.43 515.00 39.00 45.05 19 371.00 98.09 384.00 7.00 44.27 20 493.00 99.40 496.00 3.00 45.77 21 388.00 97.08 431.00 32.00 42.92 22 512.00 96.97 528.00 16.00 36.17 23 471.00 99.58 473.00 2.00 39.32 24 400.00 93.92 429.00 25.00 33.33 25 463.00 94.88 488.00 25.00 47.75 26 452.00 90.76 498.00 46.00 36.75 27 459.00 86.54 532.00 70.00 47.74 28 2/14 6/14 4/14 5/14 7/14 14% 20% 43% 60% 29% 30% 36% 50% 50% 50% Sick days 25-28 Bold=Improvement Over Baseline Mean Blue indicates percentage of days met or exceeded baseline mean value (red=percentage of days meeting/exceeding baseline with sick days controlled for) 114 Table 22 Subject 6 Improvement Over Baseline Analysis Minutes Efficiency Duration AwakeMin Activity Day 458.00 85.93 533.00 75.00 47.09 1 481.00 89.74 536.00 55.00 55.04 2 514.00 89.24 576.00 62.00 49.83 3 463.00 89.38 518.00 55.00 45.95 4 . . . . . 5 593.00 94.58 627.00 34.00 37.80 6 . . . . . 7 501.8 89.77 558.00 56.20 47.71 AVG 40% 20% 40% 60% 60% 459.00 86.62 530.00 70.00 50.57 8 468.00 79.19 591.00 123.00 67.94 9 470.00 88.67 530.00 60.00 50.94 10 . . . . . 11 555.00 92.04 603.00 48.00 55.06 12 391.00 97.26 511.00 14.00 37.77 13 484.00 88.87 530.00 59.00 63.77 14 501.00 90.11 556.00 55.00 52.70 15 538.00 95.39 564.00 26.00 48.76 16 527.00 93.94 561.00 34.00 48.66 17 509.00 91.38 557.00 48.00 43.45 18 563.00 87.15 646.00 83.00 54.02 19 491.00 85.69 573.00 82.00 50.61 20 484.00 92.54 523.00 39.00 49.90 21 501.00 91.09 550.00 49.00 47.82 22 487.00 94.02 518.00 31.00 39.38 23 506.00 94.40 536.00 30.00 40.11 24 478.00 97.95 488.00 10.00 30.94 25 511.00 90.76 563.00 52.00 42.98 26 467.00 92.48 505.00 38.00 37.43 27 434.00 90.04 482.00 48.00 48.13 28 7/20 14/20 7/20 14/20 7/20 35% 36% 70% 71% 35% 36% 70% 71% 35% 43% Bold=Improvement Over Baseline Mean Blue indicates percentage of days met or exceeded baseline mean value (red=percentage of days meeting/exceeding baseline with sick days controlled) 115 Table 23 Percentage of days meeting/exceeding baseline mean during post-intervention with summary Subject Minutes b Efficiency b Duration b Awake b Activity b 1 89% 67% 89% 67% 37% 67% 89% 67% 89% 50% 2 46/60% 36% 46/40% 50% 38/50% 43% 46/30% 57% 62/50% 38% 3 29% 55% 43% 50% 43% 55% 43% 60% 86% 55% 4 57/43% 56/57% 29% 61/36% 57/71% 61/57% 29% 50/43% 57% 50/57% 5 14/20% 57% 43/60% 43% 29/30% 50% 36/50% 43% 50% 64% 6 35/36% 40% 70/71% 20% 35/36% 40% 70/71% 60% 35/43% 60% b = baseline period Bold = Increase in Frequency Found / = Sickness Controlled Table Summary -Activity Index improved for 4 of 6 subjects (for 1 subject, after controlling for sickness, improvement was found) -Efficiency improved for 3 of 6 subjects (for 1 subject, efficiency stayed same but after controlling for sickness, improvement was found) -Minutes improved for 3 of 6 subjects (for 1 subject, when sickness was controlled for, no improvement was found= 2/6) -Duration improved for 2 of 6 subjects only when sickness was controlled -Awake after sleep onset improved for 2 of 6 subjects (3 of 6 when sickness controlled for) 116 Table 24 Daily Teacher Behavior Rating Scale Scores Summary By Subject Subject 1 Baseline Avg12 Sub 2 Baseline Avg 13.2 1 st week Avg 12 1 st week Avg 12.8 Intervention Avg 12 Intervention Avg 11.3 Last Week Avg 12.3*+ Last Week Avg 13* Sub 3 Baseline Avg 12.5 Sub 4 Baseline Avg 9.5 1 st week Avg 12.2 1 st week Avg 9.2 Intervention Avg 12.6 Intervention Avg 9.75 Last Week Avg 12.6* + ^ Last Week Avg 9.75* + ^ Sub 5 Baseline Avg 10.2 1 st week Avg 11.2 Intervention Avg 9.85 Last Week Avg 10.6 Bold = Post-Intervention Improvement * = 4 th week Improvement vs. 1 st week + = 4th week Improvement vs. Baseline ^ = Long-term Improvement (Improvement Post-Intervention vs. Baseline and 4 th week vs. Baseline) 117 Table 25 Descriptive Statistics for Comparisons Between Boys and Girls Girls Sleep Min 80 255.00 593.00 446.9875 72.50569 Girls Sleep Eff 80 72.05 99.58 88.7876 7.98126 Girls Sleep Dur 80 348.00 745.00 505.7750 69.30431 Girls Wake Min 80 2.00 173.00 56.0375 40.10854 Girls Activity Ind 79 27.56 67.94 44.0525 8.13967 Min = Sleep Minutes Eff = Sleep Efficiency Dur = Sleep Duration Wake Min = Wake Minutes After Sleep Onset Activity Ind = Activity Index N Minimum Maximum Mean Std. Deviation Boys Sleep Min 77 335.00 574.00 473.4545 40.55780 Boys Sleep Eff 77 63.39 95.17 87.5923 5.50661 Boys Sleep Dur 77 432.00 666.00 542.7143 41.43570 Boys Wake Min 77 24.00 217.00 67.5325 32.24764 Boys Activity Ind 77 21.06 61.70 39.6249 10.56291 118 APPENDIX H: GRAPHICAL DISPLAYS 119 120 121 122 123 124