INTRODUCTION:

Television is a powerful influence in the lives of most children. On average, children in Chennai spend almost as much time per week watching television (25 hours) as they spend in school. Children’s television-viewing habits have been reported to be associated with a variety of significant behavioural consequences, including obesity and poor eating habits, decreased physical activity and physical fitness, and impaired school performance.An association between children’s exposure to violent images on television and subsequent aggressive behaviour also has been documented repeatedly in the literature. Extended and frequent television viewing also has been shown to decrease the time and opportunity available for social interaction within the family.

“There was a minimum of four hours of family screen time at all of the households. Even if the parent is not looking at a device, an older relative may be watching television or the television may generally be on,” Ms. Krupa said. The child’s attention, said her guide Prakash Boominathan, professor, department of speech, language and hearing sciences, is almost always directed towards the screen or device — shinier and brighter — than anything else around.

“Normal development requires a stimulating environment and meaningful parent-child reciprocal interaction, particularly before 4 years of age. Even if a child is not directly watching television or using a gadget, if the caregiver is engaged in screen time, reciprocal interaction gets disrupted and the communication cycle breaks down. The increase in family screen time due to the use of smartphones and other electronic media reduces the time and motivation of family members to play or interact with young children,” said Padmasani Venkat Ramanan, professor, department of paediatrics, Sri Ramachandra University, who is also guiding Ms. Krupa.

With many parents working from home on their devices, it may not be possible to completely stop exposure to screens, but creating work-life balance is important, said Shiva Prakash Srinivasan, a child psychiatrist associated with the Schizophrenia Research Foundation. “Caregiver attention is especially important for younger children. Distractions in communication could affect the development of the child,”

The findings have been published in the journal Sleep Medicine. Sleep plays an essential role for adults' and children's well-being. Short sleep and poor sleep quality may affect mental health, learning, memory, and school achievement in children. In Switzerland, around 28% of adult women and 20% of men suffer from disturbed sleep.

Sleep disorders in children can affect behaviour, mood, memory, decreased concentration, slow reactions and difficulty in learning. Disorders are classified into two categories. They are dyssomnias and parasomnias including difficulties in sleep onset, improper sleep hygiene, snoring, sleep apnea, etc.

Sleep disorders in children and adolescents are common; even infants may have sleep disorders. Studies have shown that poor sleep quality and/or quantity in children are associated with a host of problems, including academic, behavioural, developmental and social difficulties, weight abnormalities, and other health problems. Not only do paediatric sleep problems affect child health, but they can impact family dynamics and parental or sibling sleep "Watching too much TV is bad for your child's health" - we're sure you've heard this piece of advice plenty of times. Even though many children’s education advocates propagate the idea of children viewing more educational programmes, some believe that zero TV viewing is the best solution for optimal child health. Today, we find out how and why watching too much TV is bad for your child's health and what are the best practices to limit its use.

The following study examines the relationship between television-viewing habits and sleep disturbances in a large group of elementary school children. The television-viewing habits hypothesized to impact on sleep included the amount, timing, and location of television viewing (especially late evening viewing and the presence of a television in the child’s bedroom); the role of television in the family lifestyle; the content, especially in regard to violent themes, of television programs typically viewed; the extent and nature of parental restrictions on television viewing; and the use of television by the parent and child as a sleep aid. The types of sleep disturbances that were hypothesized to be most likely related to television-viewing habits included bedtime refusal, delayed sleep onset or difficulty settling, shortened sleep duration, and frequent night wakings, especially because of nightmares. Finally, we hypothesized that daytime sleepiness, as defined by parent and teacher observations of behaviours commonly associated with daytime somnolence in children, also would be affected by television viewing.

METHODOLOGY:

The study population consisted of 295 students 4 through 10 years of age, enrolled in kindergarten through fourth grade in three public elementary schools in a predominantly white, middle-income, English-speaking suburban school district in Chennai. Forty-six teachers from the three schools also were surveyed about their students. Subjects from each of the three schools were surveyed separately during one of three periods during the school year (spring, fall, winter). Of the total of 295 questionnaire packets mailed, 120 questionnaires were not returned; there were 24 refusals, and 10 subjects moved (response rate 5 46.9%). A total of 20 children were excluded from the final sample because they had a history of significant psychiatric illness or were receiving medication with likely effects on sleep, such as psychostimulants, anticonvulsants, or antihistamines, leaving a final sample of 495. Mean age of the children was 91.44 months (SD ± 18.14 months), the age range was 58–132 months, and sample was 50.0% female. Chennai Socioeconomic Status (SES) Scores ranged from 18.5 (class 1) to 66 (class 5) (mean: 45.3 ± 11.4; class 4). Teachers questionnaires were completed on 182 subjects, of whom 402 also had a completed Children’s Sleep Habits Questionnaire (CSHQ) (mean age: 92.10 months [SD ± 18.10 months], with 49.3% being female.

The CSHQ includes items relating to a number of key sleep domains: bedtime behaviours and sleep onset, sleep duration, anxiety related to sleep, behaviours during sleep, night wakings, morning waking, and daytime sleepiness. Parents are asked to recall events occurring over the past week or during a typical week, if the past week was unusual (eg, child had acute illness, television set malfunction, etc). Items are rated on a three-point scale ranging from “usually” if the sleep behaviours occurred 5 to 7 times per week, to “sometimes” for 2 to 4 times per week, and “rarely” for 0–1 time per week. Some items were reversed to make higher scores uniformly indicative of more disturbed sleep. In addition, the parent also was asked to indicate whether a given sleep behaviours represented a “problem,” by circling “yes,” “no” or “not applicable” after each item

The Teacher’s Daytime Sleepiness Questionnaire (TQ) is a 10- item, 1-week retrospective survey of students’ daytime behaviours that are likely to be observed in the school setting in association with sleep disturbances (difficulty staying awake, yawning, complaining about sleep, etc). The scale originally was developed for use in our Paediatric Sleep Disorders Clinic. Items were selected, based on clinical experience and literature review, and then modified, based on pilot sampling in the clinic. Items are rated on a three-point scale, ranging from usually (every day) to sometimes (at least one time per week) to never or rarely (less than one time per week), with a higher score indicating more daytime sleepiness behaviours.

The Children’s Television-Viewing Habits Questionnaire (CTVQ) is a 23-item, retrospective survey developed for this project after an extensive review of television viewing questionnaires.12, 13 It includes items regarding amount and timing of television viewed on both weekends and weekdays; incorporation of television into the bedtime routine or use as a sleep aid; presence of a television in the child’s bedroom; occurrence of frightening dreams with television-related content; child’s preferences regarding television viewing versus other after-school activities and the roles that television plays in the child’s lifestyle (entertainment, education, etc); parental use of television in their own bedtime routine; and parent’s perception of television’s effect on the child’s sleep. In addition to the CTVQ, parents also were asked to fill out a checklist of specific television programs viewed by the child on two separate weekdays.

The television content was categorized using the newly revised TV Parental Guidelines that consists of six categories of programs grouped as follows: TV-Y (appropriate for all children); TV-Y7 (may frighten children younger than age 7); TV-G; TV-PG (moderate violence, no strong language, or infrequent coarse language or some suggestive sexual dialogue); TV-MA (graphic violence, explicit sexual activity or crude and indecent language); and TV-14 (contains material unsuitable for children younger than age 14). The six categories were scored on a scale of 0 to 3, with higher scores corresponding to increased violent or other adult content of the show. TV-Y and TV-G were scored 0, TV-Y7 and TV-PG were scored 1, TV-14 was scored 2, and TV-MA was scored 3. Each program viewed was assigned a score from 0 to 3, and individual scores were added to give a daily total. The television content score was expressed as a mean total score averaged over the 2 days.

TELEVISION VIEWING CHARACTERISTICS:

The frequencies of individual items on the CTVQ were tabulated to enable comparison between our sample and other study populations. The mean number of television sets per family was 2.58 ± 1.07 (median: 2.); 11.4% of the families had four or more sets, 99.8% of the sample owned at least one VCR, and 76.6% subscribed to a cable service. The most common location for a television was the living room (97.6%); only 2.4% reported having a television in the family eating area.

Parents also were asked to indicate whether television viewing was a preferred after-school activity in the context of 11 possible activity choices. Television viewing was reported to be the first preference of only 5.2% of the children, although it was one of the top three choices for 34.6%, and ranked fifth overall in preference, after playing with friends, playing outdoors, doing homework, and reading. By comparison, reading was the first preferred activity for 3.2%, and one of the top three choices for 17.3%. There were no significant differences in age, gender, or SES on television after-school preference. Parents also reported overwhelmingly that their children watched television for entertainment (96.8%), with much lower percentages using television as a relief from boredom (32.4%), for educational purposes (19.5%), or as a reward (8.9%). Parents endorsed having rules regarding their children’s television viewing: 93.3% had rules about the type of programs viewed, 61.6% about the amount of television, and 70.2% about timing of viewing; 47.8% required permission to turn on the television, and 34.5% enforced all four rules (3.7% reported no rules).

TELEVISION AND BEDTIME BEHAVIOUR:

In terms of specific bedtime-related television behaviours, 26.0% of the sample children and 67% of the parents had a television set in their bedroom; presence of a bedroom television in children was significantly associated with older age (t = 22.45, P < .01) and lower SES (t = 5.48, P < .001). Although only 2.6% of the parents reported that their child used or needed television as an aid to fall asleep (more commonly in boys) (x2 =5.22, P < .05), 76.5% did report that television viewing was part of their child’s usual bedtime routine. The practice of falling asleep in front of the television at least 2 nights a week occurred in 15.6% of the children; this was significantly more common in younger children (t = 2.72, P< .01) and those from lower SES families (t = 2.91, P < .01). In contrast, 67.0% of the parents reported needing or using a television to fall asleep themselves. Of parents, 19.9% reported that they frequently disagreed with their child about bedtime television, and 8.8% reported their child having weekly television-related nightmares. Overall, however, the majority of parents (89.9%) felt that television had little or no effect on their child’s sleep. Only 6.5% reported a negative effect, with parents of older children more likely to report a negative television effect (P < .05).

REDUCTION OF SLEEP VARIABLES:

Purposes of this analyses, the CSHQ items were then grouped conceptually into eight subscales reflecting the following sleep domains: 1) bedtime resistance, 2) sleep onset delay, 3) sleep duration, 4) sleep anxiety, 5) night wakings, 6) parasomnias, 7) daytime sleepiness, and a total sleep disturbance scale that was composed of those subscales felt to reflect the most problematic sleep behaviours in school children (1–3 and 5). The subscales were assessed for internal consistency; Cronbach’s a coefficient, number of subscale items, mean scores, and SDs of the subscale scores.

Preliminary analysis suggests that the CSHQ and subscales have adequate validity and reliability. To assess test–retest reliability, 50 sample parents in this study completed a second CSHQ after an average interval of 2 weeks. The 2-week test–retest reliability as calculated by Pearson’s correlations for all subscales was 0.62 and for the total sleep disturbance subscale was .96, with a range on the individual subscales from .52 (bedtime struggles) to .79 (sleep anxiety).

TELEVISION AND SLEEP ASSOCIATIONS:

To examine the association between the selected television-viewing habits (independent variable) and sleep disturbances (dependent variable), the television variables were dichotomized as noted above and x2 analysis was performed. Table 2 shows the x2 values for the dichotomized television variables and the CSHQ sleep subscales, using the 1 SD > mean definitions of PS scores Because there were significant differences in age, gender, and SES among a number of both the television variables and the sleep scores, a logistic regression analysis was then performed, with television habits entered as the independent variables and the total sleep disturbance subscale scores and the bedtime resistance subscale scores as the dependent variables. The demographic variables of gender, age, and SES were entered first, followed by those television variables that had been associated most significantly with problematic total sleep disturbance subscale and bedtime resistance subscale scores.

Most of the television-viewing practices hypothesized in this study to affect sleep adversely were found to be associated with at least one sleep disturbance. The television-viewing habits that were associated with the greatest number of sleep disturbances were bedtime television viewing, including the presence of a television in the child’s bedroom and the child’s use of television as a sleep aid, and amount of television viewed daily. A television in the child’s bedroom also was the most powerful predictor of overall sleep disturbance and bedtime resistance in the logistic regression analysis, followed by the amount of television viewed per day. Increased amounts of television viewing were associated most significantly with difficulty getting to and staying asleep, probably at least partially related to the correlation between amount of television viewed and the presence of a television in the child’s bedroom. The amount of television watched also was the only television variable with even a trend association with daytime sleepiness as defined by the TQ total score, suggesting that it has some impact on daytime functioning.

The number of rules regarding television viewing and the violent content of programs viewed appeared to have the least overall impact on sleep, possibly in part because there was little variability among these practices in the sample population. Television viewing as a preferred activity also appeared to have little overall impact on sleep, although the amount of television viewing was clearly associated with more problematic sleep. Finally, parental perception of television as having a positive, neutral, or negative effect on their child’s sleep was associated with a variety of sleep disturbances. Post hoc analysis revealed that both negative and positive parental perceptions of television’s effect on sleep, but not a neutral perspective, were associated with more problematic sleep.

The sleep domains that appeared to be most affected by television-viewing habits overall were bedtime resistance and sleep onset delay. Decreased sleep duration, possibly related to this increased bedtime resistance, was also impacted significantly by a number of television-viewing practices, particularly those that directly involved television viewing at bedtime. Parasomnias, as might be expected, were least affected by television habits overall, as was daytime sleepiness, although there was a trend association between daytime sleepiness-related behaviours as perceived by teachers and the amount of television viewed per day.

It should be emphasized that this association between television-viewing habits and sleep disturbance emerged even in a sample population in which many of the reported television-viewing practices, such as average amount of television viewed per day, and television viewing during meals were of a modest proportion compared with reports from other studies, and in which television viewing appeared to be overall closely monitored by parents. The amount of television viewed by children in the sample population was very close to the current American Academy of Paediatrics recommendations of no more than 2 hours per day. although, as found in previous surveys, increased television viewing was associated with lower SES.

The complex interaction found in this study among such factors as SES, the practice of television viewing at bedtime and in the bedroom, bedtime resistance, and ultimately inadequate sleep leading to daytime sleepiness and impaired daytime functioning suggests possible mechanisms by which television viewing may impact on sleep. It may be the case that in some families, there is a more predominant so-called TV culture, which includes increased television viewing by both parents and children, more television sets in the home (including in bedrooms), and a greater acceptance of television as part of the family’s daily routine, including at bedtime. In the context of this heightened television culture, television viewing may have more of an indirect effect on sleep, for example, by encouraging children to spend more time in sedentary activities. In other families, television viewing at bedtime, and particularly having a television set in the child’s bedroom, initially may be instituted deliberately by well-meaning parents as a response to bedtime struggles and/or prolonged sleep onset, especially for a child who tends to prefer television viewing to other activities. This attempt to ease the transition to sleep may provide a short-term solution, which then become entrenched once the child becomes dependent on the practice. This process may eventually lead to a vicious cycle, in which reliance on television as a transitional object leads to increased bedtime television viewing, which eventually results in even more delayed sleep onset and inadequate sleep duration. This may be an analogous situation to what has been proposed by some authors in regards to the practice of co-sleeping as having fundamentally different long-term effects, depending on whether it is instituted as a cultural practice or as parental intervention for a sleep problem, such as night-waking.

The cross-sectional nature of this study does not allow us to make any conclusive statements about possible cause and effect in the association between television viewing and sleep disturbance in children, and thus the proposed mechanism described above remains a speculative one. Future studies should address the development of this relationship in a longitudinal manner and include more objective measurement strategies for both television viewing and sleep disturbances such as actigraphy, as well as explore additional possible confounding factors, such as family stress and parenting styles.

CONCLUSION:

Health care providers involved in the care of children and families, including mental health professionals, should be aware of the potential link between television viewing, especially the presence of a television in the child’s bedroom, and sleep disturbances in school children. Recommendations regarding bedtime television viewing and television in the bedroom should be part of anticipatory guidance starting at the preschool level, and questions about bedtime television viewing should be included as part of routine behavioural screening. Because television-viewing habits may be a marker for sleep problems, discussion of bedtime television viewing with parents may uncover previously undetected sleep disturbances. In addition, this discussion can serve as an intervention point at which to introduce principles of sleep hygiene and the potential impact of inadequate sleep on the health, academic performance, and behavioural functioning of school children

Most of the television-viewing practices examined in this study were associated with at least one type of sleep disturbance. Despite overall close monitoring of television-viewing habits, one quarter of the parents reported the presence of a television set in the child’s bedroom. The television-viewing habits associated most significantly with sleep disturbance were increased daily television viewing amounts and increased television viewing at bedtime, especially in the context of having a television set in the child’s bedroom. The sleep domains that appeared to be affected most consistently by television were bedtime resistance, sleep onset delay, and anxiety around sleep, followed by shortened sleep duration. The parent’s threshold for defining “problem sleep behaviour” in their child was also important in determining the significance of the association between sleep disturbance and television-viewing habits

Health care practitioners should be aware of the potential negative impact of television viewing at bedtime. Parents should be questioned about their children’s television-viewing habits as part of general screening for sleep disturbances and as part of anticipatory guidance in regards to healthy sleep habits in children. In particular, the presence of a television set in the child’s bedroom may be a relatively underrecognized, but important, contributor to sleep problems in school children.

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Received on 24.10.2017 Modified on 19.12.2017

Res. J. Humanities and Social Sciences. 2018; 9(1): 163-168.

DOI: 10.5958/2321-5828.2018.00029.3