ABSTRACT

Conclusion:

Longer time spent with technological devices by 5-12 year old children during the COVID-19 pandemic was found to show a negative effect on the sleep habits of the children.

Results:

In the study, a statistically significant difference was found in technological device usage and times of children before and during the COVID-19 pandemic period (p<0.05). It was determined that 100% of children had sleep problems clinically. A statistically significant difference was found between the mean scores of students from the CSHQ based on the education and income states of their parents (p<0.05). Additionally, a statistically significant difference was found between the mean CSHQ scores based on the duration of child’s daily technological device usage (p<0.05).

Materials and Methods:

It is a descriptive study. This study was conducted with the parents of 488 children who were aged between 5-12 years old and studying in a kindergarten, 3 elementary schools and 3 secondary schools between March 2021 and June 2021. Data were collected by “Descriptive Information Form” and the “Children’s Sleep Habits Questionnaire (CSHQ)” in the study. Descriptive statistics and parametric tests were used to analyze the data.

Objective:

This study was conducted to examine the technological device usage states and sleep habits of 5-12 year-old children before and during the Coronavirus disease-2019 (COVID-19) pandemic.

Keywords:

Sleep, technological device, child, COVID-19, pandemic

Introduction

The increased use of the internet and technological devices such as computers, tablets, cell phones, television and others has become common all over the world, and especially children are the biggest consumer group of these devices (1,2). In the statement of the American Academy of Child and Adolescent Psychiatry, it was reported that the time spent in front of the screen was 4-6 hours in 8-12-year-old children and up to 9 hours among adolescents in the USA (3). Turkish Statistical Institute data reported that the internet usage rate was 50.8% in 2013 whereas it was 82.7% in 2021 among 6-15 years old children and the ratio of children, who mentioned using social media regularly, was 94.2% (4). Overuse of technological devices has been found to cause social and cognitive health problems such as social isolation, low self-esteem, shyness, depression, anxiety, attention deficit, aggressiveness and addiction (5-7). Moreover, improper or unhealthy use of technological devices by children might lead to problems such as pain/stiffness in the neck, shoulder, waist, hands and wrists, vision problems, tinnitus, fatigue, sleeplessness and weight gain/obesity (8-12). Sleep is an important requirement for the health and development of a child during the childhood period (13,14). It has significant effects on the cognitive, psychosocial and physical health of children including learning, memory and adaptation, character and academic success, physical growth, metabolism and body mass index (13). Insufficient sleep in children has been reported to increase the risk of accidents, injury, hypertension, obesity, diabetes and depression as well as it might lead to attention, behavioural and learning problems (15-17). In previous studies, it was reported that technological device usage among children resulted in sleep disorders and a change in sleep habits (1,10,11,18). In a study which was carried out in Spain, it was found that screen time longer than 120 minutes per day caused a shorter sleep time in one out of every four children (19). In their study, Fuller et al. (1) found that the children, who were watching television before sleeping, slept nearly 30 minutes less per night and their sleep quality was decreased. Also, a study from Turkey showed that the increase in screen time was correlated with a decrease in sleep time (18). The literature review has revealed that there is a limited number of studies on the relationship between technological device usage and sleep habits, and also technological device usage and sleep habits of children have not been investigated during the Coronavirus disease-2019 (COVID-19) pandemic. Pediatric nurses have the responsibility to ensure quality and sufficient sleep, which is very crucial for the healthy growth and development of children. Therefore, identification of the problems regarding technological device usage and sleep habits of children would provide convenience to pediatric nurses. In this study, it was planned to examine these two factors. This study was carried out to examine the technological device usage and sleep habits of children.

Research Questions

• How common was the usage of technological devices among 5-12-year-old children before the COVID-19 pandemic?

• Have the sleep habits of 5-12-year-old children changed during the COVID-19 pandemic?

• Does the technological device usage status of 5-12-year-old children affect their sleep habits?

Materials and Methods

Study Type

This was a descriptive type of study.

The Population and Sample of the Study

The population of the study included the parents of a total of 1766 5-12-year-old children who were registered to a total of 7 schools in a district in the Black Sea Region (a kindergarten, 3 primary schools and 3 secondary schools) between March and June 2021. The sample was calculated as 316 students with the sample size formula for a known population at a confidence interval of 95% and a total of 488 children and parents, who were literate and had internet access, were reached in the study (20).

Data Collection Instruments

The Descriptive Information Form, which was created by the researchers, and the Children’s Sleep Habit Questionnaire were used to collect data in the study.

Descriptive Information Form: There were a total of 12 questions in this form which was created by the researchers in line with the literature to determine sociodemographic variables (age, sex, education level of the parents, and income status of the family) and their features regarding technological devices they had, outside of education activities/purposes of internet usage and the change in their sleep habits. Parents were asked to answer these questions about the usage of technological devices outside of the education activities/purposes in two categories as before and during the COVID-19 pandemic (13,18,21).

The Children’s Sleep Habits Questionnaire (CSHQ): This questionnaire was developed by Owens et al. (22) in 2000 to investigate the problems related to sleep habits and problems of children. It consists of 33 items and the internal consistency coefficient (Cronbach alpha) was 0.68 for the control group and 0.78 for the intervention group. The validity and reliability study of its Turkish version was conducted by Fiş et al. (23) in 2010 and the internal consistency coefficient was found as 0.78. In this study, the Cronbach alpha coefficient of CSHQ was found as 0.69. There are eight subscales in this questionnaire screening sleeping disorders observed in children according to the international classification of sleep including bedtime resistance, sleep onset delay, sleep duration, sleep anxiety, night wakings, parasomnias, sleep-disordered breathing and daytime sleepiness. Parents are asked to score their children’s sleep habits retrospectively according to the previous week. The total test score is obtained by the sum of scores obtained from all items. Based on the frequency of habits per week, 3 is given to generally (between 5-7 times/week), 2 is given to sometimes (between 2-4 times/week) and 1 is given to rarely (between 0-1 time/week). Questions 1, 2, 3, 10, 11 and 26 are reverse-scored. Moreover, questions 32 and 33 are coded as 0,1 and 2 based on their frequency. The cut-off score of the scale is 41 and total scores more than the cut-off score are considered “clinically significant”. As the total score increases, the sleep of children is affected negatively.

Data Collection

Since online education was continuing because of the COVID-19 pandemic when the study was conducted, school administrators and teachers were informed about the purpose of the study, and the necessary institutional permissions were obtained. Then, the Google forms created by the researchers were sent to the parents and data were retrieved. It took about 10-15 minutes for the parents to fill out the questionnaire.

Statistical Analysis

Data were analyzed online with SPSS 22 (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.) program. The normality assumption of continuous data was analyzed with the Kolmogorov-Smirnov test. Student’s t-test was used to compare homogenous data between two different groups. One-Way analysis of variance (ANOVA) test was used to make a comparison of homogenous data between three and more groups. Categorical variables in all groups were compared with the chi-square test. Analysis results of continuous variables were given as arithmetic mean, standard deviation, and median (minimum-maximum) whereas categorical data were shown in frequencies. The statistical significance level was taken as p<0.05.

Ethical Aspect of the Study

Ethics approval of the study was taken from Ondokuz Mayıs University Social and Human Sciences Ethics Committee (decision no:2020/767, date: 11.27.2020). Necessary permissions were obtained from the relevant institutions to conduct the study at schools during the full-time quarantine period (29 April 2021-17 May 2021) (date: 03.02.2021; no: E-25072426-605.01-21479809). Permission was also obtained from Fiş et al. (23) to be able to use the questionnaire in the study. All stages of the study complied with the principles of the Helsinki Declaration. The consent of each parent included in the study was taken via an online questionnaire.

Results

While 51.4% of the children were between 9 and 12 years of age, the mean age was 8.41 years. About half of them (52.9%) were female students and 62.3% of the parents were between 31-40 years of age. Half of the parents (50.4%) had an undergraduate education and 43.9% had an income which was equal to their expenses (Table 1). Based on the statements of parents, 49.6% of the children were found to use tablets/computers and 57.6% were found to use cell phones before COVID-19. During the pandemic, a total of 67.0% of children stated that they used tablets/computers and 69.9% used cell phones outside of education activities/purposes. While the technological device usage rate of more than four hours per day was 16.2% before the pandemic, it was found to be 51.4% during the COVID-19 period. Moreover, tablet/computer and cell phone usage states and daily usage times of children were found to be significantly different before and during the COVID-19 period (p<0.05) (Table 2). Descriptive statistical data related to CSHQ were given in Table 3. The mean total CSHQ score was found as 77.53±6.52. Mean scores obtained from the subscales were found as 11.13±2.34 for Bedtime resistance, 1.85±0.93 for sleep onset delay, 5.02±0.73 for sleep duration, 9.35±2.38 for sleep anxiety, 7.98±1.31 for night wakings, 19.52±1.72 for parasomnias, 8.70±0.77 for sleep-disordered breathing and 16.09±2.61 for daytime sleepiness. When those with a score above 41 on the CSHQ were evaluated as “clinically significant”, all children (100%) were found to experience sleep problems. A total of 41% of the parents stated that the sleep habits of their children changed during the COVID-19 pandemic (Table 3). The mean CSHQ scores of the children were found to differ significantly based on the child’s age (p<0.05). The mean scores of the parents were also found to be significantly different based on the education and income levels and the mean CSHQ scores of the parents, who stated to have a high school degree and had an income equal to expenses, were found to be significantly higher (p<0.05). Moreover, the mean scores of the children were found to be significantly different based on their daily technological device usage times and those who spent more than 4 hours with technological devices were found to have higher scores than the others (p<0.05) (Table 4).

Discussion

In this study, tablet/computer and cellphone usage and daily usage times of the children were found to increase during the COVID-19 pandemic compared to the pre-COVID period. The study by Koran et al. (24), which was carried out with 3-6-year-old children, reported that the number of those, who used mobile phones for more than one hour, was significantly increased. In their study, Zengin et al. (25) stated that time spent on television, tablet or telephone was 3-4 hours in 36.6% and more than 4 hours in 32.0% during the pandemic. Moreover, screen times were found to increase among 71.7% of children aged between 6-13 years old during the COVID-19 pandemic in the study by Ozturk Eyimaya and Yalçin Irmak (26). Dong et al. (27) indicated that the technological device usage rate of children and adolescents all day was 27% before the pandemic whereas this rate has increased by half during the pandemic. It has been suggested that the pandemic resulted in a higher rate of technological device usage among children. Having a total mean score higher than 41 on the CSHQ in the study has shown that children experienced sleep problems at a clinically significant level (23). In this study, the total mean CSHQ score was found as 77.53±6.52, and all children were determined to have sleep problems. In the study by Tatsiopoulou et al. (28), which was conducted with the parents of preschool children during the COVID-19, 81.5% of the children were found to have sleep problems. Similarly, the study by Öztürk et al. (21) including the parents of 6-11-year-old children reported that 76.6% experienced sleep problems. The results of this study have shown similarities with other studies in the literature. In this study, the sleep habits of 9-12-year-old children were found to be affected more negatively compared to 5-11-year-old ones. Also in the study by Kotrla Topić et al. (29) which was carried out with the parents of 3-14-year-old children during the COVID-19 pandemic, it was detected that the sleep quality of children decreased as their age increased. It has been suggested that own technological device usage would likely be increased among children depending on the child’s autonomy and school needs as they get older and their sleep problems may occur as a result. Mean CSHQ scores of the children whose parents had an education level of high school were found to be higher than those with an undergraduate and postgraduate degree. In the study by Yland et al. (30) where they focused on screen time and sleep duration among school-age children, children whose mothers had a high education level were found to sleep more. However, the results of the study by Öztürk et al. (21) showed that the education level of the parents did not affect the sleep patterns of the child. The sleep habits of the children, whose parents had an income equal to their expenses, were found to be affected negatively. In the study by Aguilar-Farias et al. (31) conducted with 1-5-year-old children, children with parents who had a higher income were found to have better sleep quality. Furthermore, Bapat et al. (32) reported in their study including 10-15-year-old children that children with a high socioeconomic level slept about one and a half hours less than those with a low socioeconomic level. Dube et al. (33), similarly, noted that parents with undergraduate education and a high-income level had children with better sleep quality. In the study, technological device usage outside of the purpose of education time for 4 hours and longer per day was found to affect the sleep habits of the children during the COVID-19 pandemic. Ham et al. (34) found that children with a daily screen time for 3 hours or more had a shorter sleep duration. Beyens and Nathanson (10) indicated that more frequent television and tablet usage among children in general as well as in the evenings was found to be associated with sleeping late and waking up late. In the study by Guerrero et al. (35) including 9-10-year-old children, sleep duration was determined to get shorter as screen time increased. Besides, Twenge et al. (11) reported that children/adolescents, who spent more time in front of the screen, slept less and had insufficient sleep. Also, Almuaigel et al. (36) found a positive correlation between poor sleep score and technological device usage for 3-5 hours in their study including 3-5-year-old children. The results of this current study had similarities with the relevant data in the literature.

Study Limitations

The inability to get access to the parents who were not using phones and the internet since the study data was collected through online forms was the main limitation of the study. Furthermore, determining the use of technological devices other than sleep characteristics and educational activities/purposes of children and the fact that data obtained from the parents were based on self-reports of the parents are among the limitations of the study.

Conclusion

In this current study, tablet/computer and cell phone usage and daily usage times were found to increase during the pandemic compared to the pre-COVID period. Mean CSHQ scores of the children were found to be higher during the COVID-19 pandemic, and all children were found to experience sleep problems. It was also determined that the child’s age, parent’s education level and income status and daily technological device usage time of the children during the COVID-19 pandemic affected the children’s sleep habits. Also, the sleep habits of the children, whose parents reported no change in the sleep habits of their child during the pandemic, were found to be affected negatively. Based on the results of this study, it may be suggested that nurses working in the field of public and pediatric health can provide counselling for healthy sleep habits and healthy technological device usage. Pediatric nurses working in the clinics may provide training to the parents about the importance of sleep, sleep hygiene and technological device usage. They should consult the children and families in order to reduce technological device usage by recognizing physical problems that might occur in children due to overuse of technological devices such as vision problems, headaches and sleep problems, especially during the pandemic.

In addition, school nurses may provide training for the children, families and teachers about the importance of sleep, improvement of sleep habits and healthy usage of technological devices.

Acknowledgements

The authors thank the parents who took part in this study.

Ethics

Ethics Committee Approval: Ethics approval of the study was taken from Ondokuz Mayıs University Social and Human Sciences Ethics Committee (decision no:2020/767, date: 11.27.2020).

Informed Consent: The consent of each parent included in the study was taken via an online questionnaire.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: Z.Ö.S., Design: E.T.B., Data Collection or Processing: Z.Ö.S., E.T.B., Analysis or Interpretation: Z.Ö.S., E.T.B., Literature Search: Z.Ö.S., E.T.B., Writing: Z.Ö.S., E.T.B.

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study received no financial support.

References

Fuller C, Lehman E, Hicks S, Novick MB. Bedtime Use of Technology and Associated Sleep Problems in Children. Glob Pediatr Health 2017;4:2333794X17736972.

Zehir H, Zehir K, Yalçın FA, Yalçın M. Okul öncesi dönemde çocukların teknolojik araç kullanımı ve ailelerin bu araçların kullanımını sınırlandırmada kullandığı stratejiler. Current Research in Education 2019;5:88-103.

American Academy of Child and Adolescent Psychiatry [AACAP]. Screen Time and Children. Published: 21.06.2021 https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Children-And-Watching-TV-054.aspx

Türkiye İstatistik Kurumu. Çocuklarda Bilişim Teknolojileri Kullanım Araştırması, 2021. Published: 21.12.2021 https://data.tuik.gov.tr/Bulten/Index?p=Cocuklarda-Bilisim-Teknolojileri-Kullanim-Arastirmasi-2021-41132

Domingues-Montanari S. Clinical and psychological effects of excessive screen time on children. J Paediatr Child Health 2017;53:333-8.

Aral N, Keskin AD. Examining 0-6 year olds’ use of technological devices from parents’ points of view. The Turkish Journal on Addictions 2018;5:317-48.

Mustafaoğlu R, Zirek E, Yasacı Z, Özdinçler AR. Dijital teknoloji kullanımının çocukların gelişimi ve sağlığı üzerine olumsuz etkileri. The Turkish Journal on Addictions 2018;5:227-47.

Nsaif WS. Effecting of excessive using touchscreens devices to the children and the related with the physically and psychological children illnesses. International Journal of Computer Science and Mobile Computing 2016;5:513-24.

Jung IK, Kim JH. Effects of academic stress and academic burnout on smartphone addiction in junior high school students. The Korean Journal Of Community Living Science 2017;28:289-300.

Beyens I, Nathanson AI. Electronic Media Use and Sleep Among Preschoolers: Evidence for Time-Shifted and Less Consolidated Sleep. Health Commun 2019;34:537-544.

Twenge JM, Hisler GC, Krizan Z. Associations between screen time and sleep duration are primarily driven by portable electronic devices: evidence from a population-based study of U.S. children ages 0-17. Sleep Med 2019;56:211-8.

Mineshita Y, Kim HK, Chijiki H, Nanba T, Shinto T, Furuhashi S, Oneda S, Kuwahara M, Suwama A, Shibata S. Screen time duration and timing: effects on obesity, physical activity, dry eyes, and learning ability in elementary school children. BMC Public Health 2021;21:422.

Özvurmaz S, Çalışır H. Okul öncesi dönemdeki çocukların uyku alışkanlıkları ve beslenme durumları. Life Sciences. 2018;13:44-55.

Janssen X, Martin A, Hughes AR, Hill CM, Kotronoulas G, Hesketh KR. Associations of screen time, sedentary time and physical activity with sleep in under 5s: A systematic review and meta-analysis. Sleep Med Rev 2020;49:101226.

Paruthi S, Brooks LJ, D'Ambrosio C, Hall WA, Kotagal S, Lloyd RM, Malow BA, Maski K, Nichols C, Quan SF, Rosen CL, Troester MM, Wise MS. Recommended Amount of Sleep for Pediatric Populations: A Consensus Statement of the American Academy of Sleep Medicine. J Clin Sleep Med 2016;12:785-6.

Cankardaş S, İnce B. Çocukluk dönemi uyku problemlerinin tedavisinde davranışçı müdahalelerin etkililiği: gözden geçirme çalışması. Journal of Cognitive Behavioral Psychotherapy and Research 2020;9:237-47.

Durmuş H, Solak Y, Kaya E, Canbolat H. İlköğretim Çocuklarında Uyku Bozukluğu Sıklığı ve Obezite ile İlişkisi. J Curr Pediatr 2021;19:303-10.

Yasacı Z, Mustafaoğlu R. Does dıgıtal technology exposure affect chıldren's sleep duration? Ankara Medical Journal. 2020;20:11-22.

Cartanyà-Hueso À, Lidón-Moyano C, Martín-Sánchez JC, González-Marrón A, Matilla-Santander N, Miró Q, Martínez-Sánchez JM. Association of screen time and sleep duration among Spanish 1-14 years old children. Paediatr Perinat Epidemiol 2021;35:120-9.

Erdoğan S, Nahcivan N, Esin N. Hemşirelikte Araştırma Süreç, Uygulama ve Kritik. Nobel Tıp Kitapevi 2014;167-92.

Öztürk A, Sezer TA, Tezel A. Evaluation of Sleep and Television Viewing Habits of Primary School Students. J Turk Sleep Med 2018;5:73-80.

Owens JA, Spirito A, McGuinn M. The Children's Sleep Habits Questionnaire (CSHQ): psychometric properties of a survey instrument for school-aged children. Sleep 2000;23:1043-51.

Fiş NP, Arman A, Ay P, Topuzoğlu A, Güler AS, Gökçe İmren S, Berkem M. Çocuk uyku alışkanlıkları anketinin Türkçe geçerliliği ve güvenilirliği. Anadolu Psikiyatri Dergisi. 2010;11:151-60.

Koran N, Berkmen B, Adalıer A. Mobile technology usage in early childhood: Pre-COVID-19 and the national lockdown period in North Cyprus. Educ Inf Technol (Dordr) 2022;27:321-46.

Zengin M, Yayan EH, Vicnelioğlu E. The effects of the COVID-19 pandemic on children's lifestyles and anxiety levels. J Child Adolesc Psychiatr Nurs 2021;34:236-42.

Ozturk Eyimaya A, Yalçin Irmak A. Relationship Between Parenting Practices and Children's Screen Time During the COVID-19 Pandemic in Turkey. J Pediatr Nurs 2021;56:24-29.

Dong H, Yang F, Lu X, Hao W. Internet Addiction and Related Psychological Factors Among Children and Adolescents in China During the Coronavirus Disease 2019 (COVID-19) Epidemic. Front Psychiatry 2020;11:00751.

Tatsiopoulou P, Holeva V, Nikopoulou VA, Parlapani E, Diakogiannis I. Sleep patterns and sleep disruptions in preschoolers midst the COVID-19 Pandemic lockdown in Greece. Research Square 2021. [Preprint] Available from: https://assets.researchsquare.com/files/rs-889902/v1/8bbd7057-e8b1-42e7-95d8-4f0a23284a2e.pdf?c=1636472041

Kotrla Topić M, Varga V, Jelovčić S. Digital technology use during the COVİD-19 Pandemic and ıts relations to sleep quality and life satisfaction in children and parents. Društvena istraživanja: časopis za opća društvena pitanja 2021;30:249-69.

Yland J, Guan S, Emanuele E, Hale L. Interactive vs passive screen time and nighttime sleep duration among school-aged children. Sleep Health 2015;1:191-6.

Aguilar-Farias N, Toledo-Vargas M, Miranda-Marquez S, Cortinez-O'Ryan A, Cristi-Montero C, Rodriguez-Rodriguez F, Martino-Fuentealba P, Okely AD, Del Pozo Cruz B. Sociodemographic Predictors of Changes in Physical Activity, Screen Time, and Sleep among Toddlers and Preschoolers in Chile during the COVID-19 Pandemic. Int J Environ Res Public Health 2020;18:176.

Bapat R, van Geel M, Vedder P. Socio-Economic Status, Time Spending, and Sleep Duration in Indian Children and Adolescents. J Child Fam Stud 2017;26:80-7.

Dube N, Khan K, Loehr S, Chu Y, Veugelers P. The use of entertainment and communication technologies before sleep could affect sleep and weight status: a population-based study among children. Int J Behav Nutr Phys Act 2017;14:97.

Ham OK, Sung KM, Kim HK. Factors associated with screen time among school-age children in Korea. J Sch Nurs 2013;29:425-34.

Guerrero MD, Barnes JD, Chaput JP, Tremblay MS. Screen time and problem behaviors in children: exploring the mediating role of sleep duration. Int J Behav Nutr Phys Act 2019;16:105.

Almuaigel D, Alanazi A, Almuaigel M, Alshamrani F, AlSheikh M, Almuhana N, Zeeshan M, Alshurem M, Alshammari A, Mansi K. Impact of Technology Use on Behavior and Sleep Scores in Preschool Children in Saudi Arabia. Front Psychiatry 2021;12:649095.

The Examination of Technological Device Usage and Sleep Habits among the Children Before and During the COVID-19 Pandemic