Promoting Sleep and Balanced Screen Time among School-Aged Children with Neurodevelopmental and Mental Health Disorders: A Parent Perspective

Abstract

Background:

Children with neurodevelopmental and mental health disorders (N/MHD), such as autism spectrum, mood disorders, and anxiety, are more likely to engage in excessive screen time, receive insufficient sleep, and to have obesity than neurotypical peers. However, little is known about how parents of these children approach promoting sleep and balanced screen time.

Methods:

We conducted semistructured interviews with 24 parents of children aged 8–15 years with a diagnosis of N/MHD to assess barriers and facilitators to promoting sleep and balanced screen time. Interviews were transcribed, double-coded using constant comparative methods, and summarized into themes using NVivo 11.

Results:

Many parents described children's chronic sleep challenges, often compounded by screen use and no clear solutions. When feeling overwhelmed, some parents reluctantly reported co-sleeping or allowing gaming devices in bed. Nearly all participants reported chronic, occasionally severe, conflict when managing children's screen time, with some parents experiencing opposition and physical aggression. Parents struggled to weigh the benefits of screen use (i.e., behavior management, learning, and social connection) with the costs (i.e., reduced self-care and limited physical activity). To combat barriers, parents described firm routines (i.e., “screens off” time and consistent bedtime on weekdays and weekends), moderating access (i.e., shutting down internet and no device in bedroom), verbal priming, and coping strategies (i.e., music and books).

Conclusions:

Parents of children with N/MHD face unique challenges in promoting sleep and balanced screen time. Given these behaviors may impact weight status and mental health, future interventions should examine ways to support parents in reducing conflict while promoting healthy habits.

Background

As of 2019, an estimated 7.7 million children in the United States had a mental health disorder diagnosis (e.g., depression, anxiety, and bipolar), which affects emotions, thinking, and behavior.¹ Moreover, neurodevelopmental disabilities (e.g., autism spectrum disorder and attention-deficit/hyperactivity disorder), which affect a child's behavior, memory, or ability to learn, are also on the rise in the United States, impacting an estimated 17% of children aged 3–17 years.² More than half of children with a neurodevelopmental disorder will also experience at least one mental health disorder,^3,4 with some experiencing three or more diagnoses. Unfortunately, stressors and population-wide changes occurring in response to COVID-19 will likely increase the prevalence of mental health disorders and increase the needs of children who already have them.⁵ Although each child's challenges will vary, children with neurodevelopmental and mental health disorders (N/MHD) face many similar barriers to experiencing full health and quality of life.^6–8

Notably, children with N/MHD are at a significantly increased risk for childhood obesity compared with neurotypical peers.⁹ For example, children with autism spectrum disorder, especially those with behavioral challenges, are twice as likely to have overweight or obesity^10–12 and face a higher risk of diabetes and heart disease in their teens and adulthood than typically developing peers.^13,14 Similar trends are seen for children with mental health disorders.^15,16 Over time, adults with severe mental health disorders also experience excess mortality attributed to metabolic disease, facing a 10–20 years reduced life expectancy.^15,17,18

Multiple studies have demonstrated that obesity-related lifestyle factors, including excessive screen use and inadequate sleep, have all been observed in children with N/MHD.^19–22 Research shows a consistent and robust association between bedtime media device use or access to media devices at night and inadequate sleep.²³ Unfortunately for children with N/MHD, poor sleep can be especially damaging, as it may result in reduced energy for physical activity and socialization, along with increased depressive symptoms.^24–26 Childhood obesity can reduce mental health through stigma, bullying, low self-esteem, and exercise avoidance, thus creating a cycle of poor physical and emotional health.²⁷

At the family level, promoting positive health parenting strategies is essential to preventing and treating obesity.²⁸ Still, typical approaches may not always be appropriate for families caring for children with unique medical and behavioral needs. Despite evidence of health disparities around obesity among this population of children, current literature is limited in describing strategies for parents attempting to address sleep and media use.

Therefore, the purpose of this study was to describe specific parent-identified barriers and strategies in addressing sleep and screen time among children with N/MHD. Our study was nested in the context of a broader exploratory analysis of health parenting of children with N/MHD, published elsewhere.²⁹ The original study identified child and parent-focused barrier themes and generalized parenting strategies, including allowing agency, boundaries, diversion or distraction, positive reinforcement, family engagement, and positive role models. For the present analysis, we found parents' accounts of addressing sleep and screen time yielded significant rich data that did not exist elsewhere in the literature.

Methods

Participants

The study aimed to recruit parents with at least one school-aged child diagnosed with an N/MHD and lived with the child at least part time. All recruitment was conducted through a therapeutic day school in Massachusetts, serving children in kindergarten through 10th grade who experienced emotional, neurological, and learning difficulties that impacted their ability to succeed in other educational settings. Approximately 100 parents were eligible to participate in the study.

Recruitment

Study information was distributed from school during the 2016–2017 academic school year through e-mail, hard copy letters, and announcements at parent support groups. To enroll in the study, parents completed an online consent form and demographic questionnaire and provided contact information so that study personnel could reach out to arrange an interview. All study participants received a $25 gift card after the interview. Recruitment efforts continued through 2 weeks with no additional contacts, at which point 25% of eligible parents had enrolled. The study was conducted in accordance with the Helsinki Declaration, and all study procedures were approved by the Institutional Review Boards at the Harvard T.H. Chan School of Public Health.

Design and Procedures

Our study utilized an exploratory qualitative design to investigate health parenting experiences with N/MHD with respect to sleep and screen time. A brief demographic questionnaire and in-depth semistructured interview protocol were used to collect data. Both tools focus specifically on the child attending the therapeutic day school, even if parents had other children. Complete tool development and research personnel training procedures have been published elsewhere.²⁹

The demographic questionnaire was administered electronically and collected information about the parent and their reference child. Parents reported on their relationship to their child, race/ethnicity, education, and marital status. They also stated their child's age, gender, grade level, and neurodevelopmental/mental health diagnoses (autism, mood disorders, etc.). Finally, parents reported on select children's health behaviors around screen time and sleep using a Likert scale with options of never, less than once per week, once per week, two to four times per week, nearly daily or daily, two to four times per day, or five or more times per day.

The semistructured in-depth interview guide included general open-ended questions about health parenting for the reference child (see complete guide in Supplementary Data S1). Participants were asked to choose two health topics that they were most concerned about for their child out of four options (i.e., healthy eating, screen time and media use, getting enough exercise, and getting a good night's sleep) to guide the focus of the interviews, which ranged from 40 to 75 minutes. However, despite their initial choices, all participants did eventually discuss both sleep and screen time. Interviews were administered in person or remotely through phone or video chat and were audio recorded. Building upon findings from the original study that identified general barriers and facilitators to promoting healthy behaviors overall,²⁹ for this study, the novel analysis focused narrowly on parent-identified barriers and their specific individualized strategies used to address sleep and screen time among their children. The hope for this study was to offer detailed and constructive targets for future interventions.

Data Analyses

Audio recordings were transcribed verbatim, de-identified, and reviewed by the original interviewer. Data were analyzed within main themes for barriers and strategies to promoting sleep and balanced screen time, which were developed a priori based on current parenting literature²⁹ and coded under sleep or screen time. Three reviewers coded 10 randomly selected initial transcripts (A.B., R.K., and R.B.) and, using constant comparative methods, identified emergent subthemes using NVivo 11. To ensure intercoder agreement, in-depth thematic coding occurred using discussion, revision, and review to the satisfaction of all. After the complete codebook was finalized, two researchers (A.B. and R.B.) coded and reviewed all remaining transcripts. Codes were then organized into tables by theme, and illustrative quotes were extracted and reviewed. Quantitative data from the brief demographic questionnaires were summarized using means and frequency distributions using Stata/SE 12.1

Results

Participant Characteristics

In total, 24 parents completed in-depth interviews. Participant demographic characteristics are reported in Table 1. The overwhelming majority of parent participants identified as white (non-Hispanic) mothers with at least some college education. Most (63%) were married or cohabitating with partners; 29% identified as divorced. The vast majority of reference children discussed in the interviews had multiple diagnoses (88%), with a majority having a diagnosis of attentional/attention-deficit/hyperactivity disorder (67%), anxiety (67%), and/or a mood disorder (i.e., depression and bipolar disorder) (58%). Half of the children also had a diagnosis of autism spectrum disorder. Most were male (75%) and ranged from 3rd to 11th grade (mean age 11.6 years).

Table 1.

Characteristics of 24 Parents and Their Children Attending a Therapeutic Day School in Massachusetts

Parent participant characteristics (%)	n = 24
Relationship to child
Mother	95.8%
Father	4.1%
Race/ethnicity
White (non-Hispanic)	95.8%
White (Hispanic)	4.1%
Level of education
High school diploma/GED	4.1%
Some college or Associate's degree	20.8%
College degree	20.8%
Postgraduate/professional degree	52.1%
Marital status
Married or cohabitating	62.5%
Divorced	29.1%
Never been married	8.3%
Child characteristics	n = 24
Age in years, range (mean)	8–15 (11.6)
Gender (%)
Male	75.0%
Female	25.0%
Grade level (%)
Elementary (3rd–5th)	29.1%
Middle (6th–8th)	37.5%
High school (9th–11th)	33.3%
Child eligible for free or reduced cost-lunch (%)	13.0%
Diagnoses (%)
Multiple co-occurring diagnoses	87.5%
Autism spectrum disorder	50.0%
ADHD	66.7%
Mood disorder (e.g., depression and bipolar)	58.3%
Anxiety disorder	66.7%
Declined to state	4.1%
Number of siblings (%)
0	37.5%
1	33.3%
2 or more	29.1%
Sibling(s) with special needs	29.1%
Child health behaviors
Physical activity
Days per week of 60+ minutes of moderate to vigorous physical activity, mean (SD)	2.1 (2.0)
Recreational screen time^a
Weekdays: spends ≥8 hours per day	54.1%
Weekend days: spends ≥8 hours per day	79.1%
Child has a usual bedtime	91.6%

Includes watching TV, playing computer/video games, surfing the internet for nonstudy reasons.

ADHD, attentional/attention deficit-hyperactivity disorder.

Parents also reported on their child's health behaviors. Few children were achieving recommended daily physical activity, and most were spending >8 hours daily on recreational screen time on both weekdays (54%) and weekend days (79%). The lowest level of screen usage recorded was 4 hours per day, and some parents indicated that their child was using some sort of screen use nearly at all waking hours of the day. Almost all parents reported that their child had a regular bedtime (92%).

Barriers to Promoting Sleep and Balanced Screen Use

Key themes, subthemes, and illustrative quotes regarding barriers to promoting sleep and balanced screen use are described in Table 2. Nearly half of parents said their children had chronic sleep challenges (i.e., falling/staying asleep and bedtime anxiety), and most identified screen use as a major obstacle in encouraging sleep. A few parents explained that they began providing screens in bed to reduce their child's anxiety. Several parents said they had exhausted all options for ways to help their children sleep and felt resigned. Multiple parents described reluctantly resorting to co-sleeping with children because they could not find other solutions. One mother of an 8-year-old boy explained, “The most difficult thing is I need a break. I need him to go to sleep.. . He still sleeps with me, which he needs to sleep in his own room. For me, that's a huge issue.” (ID #27)

Table 2.

Parent-Identified Barriers to Promoting Sleep and Balanced Screen Time for Children with Neurodevelopmental and Behavioral Health Disorders: Themes, Subthemes, and Illustrative Quotes

Barriers to promoting sleep
Theme 1: chronic difficulty falling or staying asleep
Subthemes	Illustrative quotes
Anxiety impacts sleep	“She has a lot of challenges when it comes to sleep, a lot around the anxiety and a lot around if the routine is disrupted that can throw her off completely on her sleep.” ID #11
Anxiety impacts sleep	“He just is anxious about sleeping.” ID #27
Bedtime challenges	“He has a hard time settling down to go to sleep. Then sometimes even when he gets off to sleep, maintaining sleep. He'll wake throughout the night, but he definitely has a hard time settling down to get to sleep, and he wakes up very tired in the morning.” ID #04
Bedtime challenges	“We have been called home by babysitters. None of them can put her to sleep.” ID #16
Parent exhaustion	“The most difficult thing is I need a break. I need him to go to sleep.” ID #27
Theme 2: limited solutions
Subthemes	Illustrative quotes
Out of options for improving sleep	“I guess, for us, it's the frustration of we're at our wits end at what else we can do to help him [sleep]. The question of whether or not there really is anything else we can do to help him.” ID #04
Out of options for improving sleep	“Someone said for us maybe try to sit there with him for a while, but sometimes I don't feel good. It's hard for us to sit there with him. I wish there was some other method for him—lately he's really havin’ a bad night sleeping.” ID #14
Co-sleeping as a final resort	“He still sleeps with me, which he needs to sleep in his own room. For me, that's a huge issue. I really would like him to sleep in his own room. He doesn't sleep through the night.” ID #27
	“I'd just have to sit with him on his bed to get him to go to sleep because his anxiety levels were so huge.” ID #25
	“There was a brief three-month period that we had her out of the [our] bed, but then she started at school. That was too anxious-making for her, so she came back in the bed with me. I have to lay down next to her, so I'm falling asleep.” ID #16
Theme 3: Screen use disrupting sleep
Subthemes	Illustrative quotes
Nighttime screen use	“We try to turn the TV off. He'll turn it on at 1:00 or 2:00 in the morning.” ID #14
Nighttime screen use	“We got into a bad habit of him bringing a DS or a little video thing to bed because it would actually calm him down, but yet, staring at a screen before going to sleep is such a bad thing.” ID #25
Early waking to use screens	“They'll [child and brother] actually get up early so that they have more time before school [to play video games]. Definitely, yeah, it affects their sleep.” ID #06
	“I guess the biggest challenge… is keeping him from turning it on first thing in the morning. That it's the first thing he does, that it's his first go-to in the morning.” ID #08
	“On the weekend he could get up early in the morning and be on it all day long, to the end.” ID #14
Barriers to managing screen time
Theme 1: balancing the cost-benefit of screen use
Subthemes	Illustrative quotes
Behavior management	“I have been using media inappropriately as a babysitter at times. When I need to get stuff done around the house, I've been lazily allowing her time on the tablet when she shouldn't.” ID #28
	“Well, I use screen time as a bribe. Like this morning… before he could go back to his screen time, he had to finish his whole breakfast and his medications.” ID #02
	“When his dad and I divorced, which meant that when he was at either of our houses you only had one adult taking care of him instead of two. My impression is he had more screen time once we separated because he wasn't supervised because I was preoccupied with other things.” ID #06
Learning and social enrichment	“I wouldn't say that any time on the screens is bad. Actually, I think he's really gotten a lot of stuff out of doing the Minecraft. The creative part of it. Building. Then, when he's working with friends, that's been a great help with his socially.” ID #03
	“I, also, don't wanna completely discourage the video games because I think it's a connection to his friends and his peers.” ID #02
	“The quality of his screen time is actually quite good. I know this sounds crazy, but he taught himself physics, Newtonian physics.” ID #17
Theme 2: chronic conflict managing screen use
Subthemes	Illustrative quotes
Always a fight	“It usually is very difficult to take away his iPod and games.” ID #07
	“Let's just say sometimes he fights me less than others, but it's always a fight.” ID #06
	“Like last night when we were trying to get the iTouch away from him, my husband got really upset with him, and very angry with him, and then [child] started getting rude with my husband. It became just disruptive to the whole family. We were all trying to eat dinner together, and it sort of just created a lot of stress.” ID #18
Physical aggression or oppositional behaviors	“Taking it [device] away is the hardest, because he will call people names, he will stomp, he will throw things. He will calm down eventually, but it takes a whole effort to try to take it away from him, because he just wants to have it.” ID #14
	“It can get pretty loud and crazy. I try to close the door, don't get angry at him, ask him not to get angry. He gets really loud and resists.” ID #06
	“I mean, there's some serious problems when he loses his temper. If he makes a normal mistake that a teenager makes or he's disrespectful where if he loses his privileges it's been really extreme behavior lately like holding a knife to his wrist… If he thinks he's going to lose access to it [screens] as a consequence to his actions it's been really dangerous lately.” ID #12
Different rules at different homes	“When she goes to her dad's, it's pretty much like all screens, all the time. I don't have any control over that.” ID #09
Different rules at different homes	“It's all really based on the environment of what's going on in [Dad]'s home when [child] is there.. . Basically, he gets more screen time because of that, in order to keep other people happy.” ID #06
Theme 3: Intensity of desire for screen use
Subthemes	Illustrative quotes
Perceived media addiction	“It's almost as if it's an addiction… It's quite a challenge.” ID #07
Perceived media addiction	“If allowed, he would be on screens 24/7. He becomes like a different person sometimes when he's on the screen, and that causes a lot of issues within our family.” ID #18
Media use interrupts daily functioning	“What he's not good at managing is like if he has homework he will blow through his homework, right or wrong, who cares, to get to screen time. Then when I hafta try to redirect him back to homework to, okay, it's nice that it's done, but we need to take our time and do it right. It's always kind of a challenge.” ID #12
Screen use impacting social relationships	“He was so interested in electronics almost to the exclusion of anything else. It limited his development of social interactions because there was only one thing he wanted to talk about.” ID #08
Screen use impacting social relationships	“We're worried it [gaming] could interfere with her friend time.” ID #11
Child has no other interests	“I don't mind hard work, but I really have to work hard to get him to choose something else with his free time.” ID #12
	“He never does well [without screens]. I hate to say that. If I didn't—I mean there would never be a day that [child] would just decide not to use the iPod on his own. His number one choice of activity is his iPod.” ID #07
	“He'll sit on the couch or in a chair all day long and play his video games, and don't wanna do any kind of physical, outside or anything, play” ID #14
Theme 4: navigating content of media
Subthemes	Illustrative quotes
Unsure how to limit access to certain types of content	“I think the other thing that I guess I'm concerned with is just what he's actually viewing on that device, and that, I think, goes to health and wellness. It's very difficult to control it even though we have restrictions on it, and there's always ways around stuff.” ID #18
Unsure how to limit access to certain types of content	“As she gets older and learns how to download things and then delete them before I check her tablet, things are gonna get trickier.” ID #28
Dealing with perceived vs. real friendships	“It can create a false sense of friendship. He sometimes plays games online with other people, and they're not people he knows in real life. It feels like he's—it feels like he is playing with a friend, but it's not—I don't know how to explain this. It's not necessarily a real friend. That concerns us a little bit.” ID #23
Dealing with perceived vs. real friendships	“Something that I think is not totally positive, is he's able to make friends really easily through a lot of these media outlets that he has. It's about something that [child] really struggles with is making any kind of friends. It's good for him on an instant basis that he has that ability to do that online, but yet, at the same time it's negative for his social skills and growth.” ID #06
Exposure to food advertising	“He watches other behaviors on You Tube that are not necessarily healthy. Computer games, he considers himself a computer gamer. A lot of that subculture is embracing eating bad food… He thinks it's okay to eat bad food and a lot of it, based on what he sees in the media.” ID #20

Overwhelmingly, conflict around addressing screen use was a key theme across nearly all interviews. Subthemes of physical aggression and verbal opposition (i.e., swearing, yelling, and name-calling) occurred in almost half of all interviews describing efforts to curtail screen time. The intensity of desire for screen use, described by some parents as “addiction,” caused many children to stay up late, wake up excessively early, avoid socializing, and inhibit self-care and home responsibilities. A mother of a 13-year-old boy (ID #12) explained, “I don't mind hard work, but I really have to work hard to get him to choose something else with his free time.” Parents struggled to weigh the benefits of screen use (i.e., behavior management, learning, and social connection) with the costs (i.e., fighting and irritability). Some parents admitted that screens helped their child self-regulate in public settings or at home so that the parent could complete housework or other tasks. Finally, parents expressed uncertainty about how to limit access to inappropriate media content, including exposure to extensive food advertising online.

Strategies for Promoting Sleep and Balanced Screen Use

A summary of key themes, subthemes, examples, and illustrative quotes is presented in Table 3. To promote sleep, parents described the importance of established routines at bedtime, including having a specific bedtime enforced even on weekends. Other routines included a prebedtime ritual (shower, reading, and music) and a firm “screens off” time between media use and sleep. “He can't use screens after 8:00 so that it's an easier transition to bedtime,” explained one mother (ID #08). Some parents also described that keeping wake-up times consistent helped with their child's evening sleep. One mother explained, “not letting her sleep too late on the weekends is important.” (ID #11)

Table 3.

Parent-Identified Strategies for Promoting Sleep and Balanced Screen Time for Children with Neurodevelopmental and Behavioral Health Disorders: Key Themes, Subthemes, and Illustrative Quotes

Strategies to promoting sleep
Theme 1: routines
Subthemes	Examples	Illustrative quotes
Presleep routines	Clear routines before bed Shower time, reading time, and music time	“That routine, pretty much, consists of he takes his nighttime medicine, he goes and takes a shower, prepares things for the next morning. Then he's allowed to read or listen to music before he goes to sleep. He has to have lights out by 9:00, and we tell him that at—by 8:30, he's gotta be listening to quiet music, and we try to get him to put the books away.” ID #04
		“We did spend some time, and [our school] was helpful with this idea of establishing daily routine that's gonna help him unwind and get ready for bed.” ID #22
		“It's just starting early, starting the whole process early, giving her reassurance, and trying to get her to calm down. Starting the process early is important.” ID #11
A firm “screens off” time	Set time when screens are shut off to transition to bed	“He can't use screens after 8:00 so that it's an easier transition to bedtime.” ID #08
		“[We] make some space between screen time and bedtime.” ID #03
		“I would never let him have iPad time or video game time right before bed. I think that would be way too stimulating for him.” ID #23
		“Well, I think it [screen use] was really interrupting his sleep a lot before, so I restricted to no screen time after a quarter after six, now. That has made his sleep better quality and better able to fall asleep without medication.” ID #02
Consistent sleep/wake routines	A set time for going to sleep A set wake up time Same bedtime schedule on weekends	“I'm really strict about bedtime. I don't let her stay out past bedtime.” ID #09
		“I think the most successful things were sticking with a bedtime, because then he knew what was expected every night.” ID #04
		“Getting her on a schedule, so not letting her sleep too late on the weekends is important.” ID #11
		“I approach by having a schedule that is the same seven days a week, or whenever he's with me, not matter what day it is. He sleeps well almost all the time. It's not much of a problem.” ID #20
Theme 2: soothing
Subthemes	Examples	Illustrative quotes
Encouraging self-soothing	Soothing sensory inputs (music, lights, and pets) Having a strategy for nighttime wakeups	“We did buy this kind of light…and it's round, and it turns colors, like blue, then it'll turn to red, then it'll turn softly into another color. He seems to like that all night long, he'll leave it on.” ID #14
		“We got him this thing called a Tranquil Turtle.. . it has lights and soft music. Sometimes he'll use that as his last music to go to bed, but sometimes if he wakes up during the night, he'll turn that on to try to lull himself back to sleep.. . Getting out of bed, and coming to get me, or yelling for me, made him more awake, which made it even harder for him to go back to sleep. I think by him staying in his room, and not feeling dependent on me to help him to get back to sleep, has helped him.” ID #04
		“We're trying to work on ways that she can cope herself or she can find ways to relax herself so that she doesn't need us necessarily to step in. I think she's getting better when she'll pet her cat and she'll like lay down on the bed and pet her cat and try to sleep.” ID #11
		“You can get him to sleep, but then he was waking up. We did books on tape for a little while. He could even listen to that with headphones.” ID #25
Parent soothes child	Parent gives backrubs, tickles, soft touch Parent lays next to child until asleep	“He does like you to rub his back. That's soothing for him, like if you kind of scratch it softly. He does like you to put your fingers through his hair. Something like a soft touch for him.” ID #14
		“I have to lay down next to her, so I'm falling asleep.” ID #16
		“He has to get tickles every night. He's very insistent on a whole ticklefest before he'll go to bed.” ID #27
Strategies to promoting balanced screen time
Theme 1: clear communication
Subthemes	Examples	Illustrative quotes
Setting expectations	Set limits at beginning of the day	“The best thing to do is if we can limit it in the beginning, it's much easier to deal with it. If he has carte blanche and he's allowed to have it all day, that's when it becomes more and more difficult. The longer he has it, the harder it is to take away.”
Visual supports	Using a timer	“He fights it, but he responds better if I set a timer.” ID #02
Priming	Giving a warning before ending screen time	“We'll say, ‘You have five more minutes you have to turn it off.’” ID #08
		“We need to be aware we're gonna eat in 15 minutes, we need to say, ‘[Child], we're gonna eat soon, you need to get to a save point, or point where you can pause your game.’” ID #22
		“[During screen time] I would hafta say to him, ‘In an hour you need to take out the trash.’ It still might not go well, but it's not something he would be able to do right now or in 10 minutes or even in 15 minutes.” ID #12
Positive reinforcement	Talk positively about appropriate media use Incentives to use media appropriately	“I say like, ‘It was really great how you got off the computer yesterday. That made it possible for you to do this today.’ Or, ‘It was great how you did your homework first, so you had your full computer time. Let's keep it up.’” ID #03
		“He has a plan, kind of a behavior and household chore morning and evening routine plan that is tied to earning money. Appropriate use of the devices in the morning is part of that, that he begins his routine without having turned on his phone, that he does everything else.” ID 08
Theme 2: moderating access
Subthemes	Examples	Illustrative quotes
A firm “screens off” time	Routines for screens off (typically 8:00 pm)	“During the week and school nights that iPod is off at 8:00 and you're to read from 8:00 to 9:00.”ID #07
		“He can't use screens after 8:00 so that it's an easier transition to bedtime.” ID #08
		“The rule in our house is when I come home from work, that's when they have to get off the computer.” ID #06
Limits on screen locations	Not allowing screens or phones in bedroom No screens on while eating	“[Child's name]'s not allowed to have his phone in his bedroom” ID #01
		“We have a rule, no one can be doing any screen time when we're eating. That's not okay, you can't get up and leave the table and go play video games, while people are eating.” ID #22
Parent removes access as needed	Shut down internet at night Remove device Remove inappropriate or distracting apps	“As he's been older, and staying up later, we have to basically shut down the internet.” ID #03
		“Sometimes, at night, I'll take his iPad into my room cuz I wouldn't wanna keep it in his bedroom. It would just be too much temptation.” ID #02
		“I say to him, you already had two hours in the van, now you only have an hour left. Then I take it away for the rest of the night.” ID #18
		“Then we made some new house rules which was that my daughter is not allowed to download apps unless it's vetted by either myself or the nanny.” ID #28
Theme 3: soothing
Subthemes	Examples	Illustrative quotes
Allowing music in bedroom in place of screen	Use of a radio or iPod instead of tablet	“We let him take his iPod in his bedroom because it has music on it. He likes to play music to go to sleep, which works great.” ID #01
Promoting coping strategies to transition from screen use	Redirect to another preferred activity (reading, Legos) Allow to go to a safe space Encourage soothing such as deep breaths or a walk	“There usually has to be something other to pacify him with. Luckily with him, he does like his reading, so I'll usually tell him that he needs to stop and he needs to read. He also does like to build with Legos and stuff, so I'll tell him, ‘Enough with the iPod,’ and he needs to play with his Legos.” ID #07
		“And when he gets upset because of the video, the screen time that he really wants and how we have to bring him down. It's gonna be okay, kinda redirect him. It'll be fine. He'll get upset for a while but then he'll finally calm down.” ID #14
		“Just teaching him, reminding him what his expected behaviors are for getting off of technology, and reminding him to use a coping strategy, such as taking a deep breath, or squeezing his fists together, taking a walk out of the environment.” ID #23
		“He generally will calm down and see the point that we're trying to get across, but it's sometimes he needs sensory—he needs to get into a tight space like a bed or closet or he likes to sit under tables.” ID #18
Theme 4: encouraging autonomy
Subthemes	Examples	Illustrative quotes
Earning screen time	Earning screen time for doing homework or chores	“He can't use the game console until he's completely finished his homework and his chores. He's very good about getting those things done so that's his reward.” ID #22
		“By reading 15 minutes, you can have a half hour of screen time.” ID #02
		“He's rated on three behaviors at school, and if any of those behaviors fall below the average. .. then we limit his screen time proportionately to that.” ID #18
Negotiating screen limits	Discussing time limits Giving buffer time	“I'll start ridiculously low. ‘You can have an hour.’ He'll be like, ‘Four hours.’ Then I'll be like, ‘“Two hours.’ .. We negotiate and I go ridiculously around my goal, so I end up meeting in the middle and getting it.” ID #12
		“We had to come to an agreement of what she can do. I agree she can't be on the Instagram at 3:00 in the morning obviously, or even at midnight or 10:00. We've agreed that she has to be off the Instagram at 9:00 but she can listen to music.” ID #11
		“Really, we want him off by—let's say it's 8:00 p.m. We'll say, ‘Okay, 7:45 p.m., you need to get off.’ That gives him a little time to have to negotiate with. Then, we can say, ‘Okay, you can watch one more. How long is it?’ Set it up so that there's a, ‘Okay, I'm gonna do this, and this will take 15 minutes. Then, at the end of that—’ so that he has a role in deciding where it ends.” ID #03
Theme 5: role modeling
Parent demonstrates appropriate media use	Keeping phone out of bedroom Limiting own screen time Encouraging physical activity in place of screen use	“At night I plug my phone in, in the living room so it's not in the bedroom when I go to sleep.” ID #22

About a quarter of parents described specific child self-soothing strategies, including peaceful music, nightlights, weighted blankets, stuffed animals, or pets. Other strategies required the parent to offer soothing through backrubs, tickles, or soft touch. A few parents shared that they needed to lay with their children until they fell asleep each night or co-sleep through the night, but that posed long-term challenges. A mother of an 11-year-old boy (ID #14) shared, “It's hard for us to sit there with him. I wish there was some other method.”

Having clear communication and moderating access emerged as the strongest strategy themes identified in managing screen time. As a father of a 14-year-old boy (ID #22) indicated, “[Child] is on the spectrum. He does respond well to structure, although he may resist it, very strongly in the beginning. We try to make the rules very explicit.” Parents talked about having to set firm limits on the timing of media usage to “make some space between screen time and bedtime” (i.e., screen cutoff time and limited usage during certain hours), and removing access by shutting down the internet or physically removing devices from a child's room. Parents also discussed the importance of priming to prepare a child (i.e., using a timer and reminders of “five more minutes”) and then having a distraction in place such as reading or Legos when screen time ended. Some parents promoted coping strategies such as deep breathing or a safe sensory space to de-escalate their child and avoid a meltdown. Many parents explained that negotiation could be helpful as it gave their child more control while allowing them to demonstrate flexibility and settle on agreed limits. Finally, parents explained that screen time could be limited more naturally by encouraging autonomy so children could earn it for completing required tasks such as homework, chores, and self-care activities. Only a few parents described role modeling healthy media use by keeping their phones outside of their bedrooms or limiting their own screen time.

Discussion

Based on this exploratory study of parent-identified barriers and strategies for addressing sleep and screen time in children with N/MHD, it is clear that there are many opportunities to provide support. Child sleep challenges were a chronic problem for many families in our study and often compounded by screen use and no actionable solutions. Managing screen time was reported as a source of chronic conflict for nearly all participants, with some parents describing opposition and physical aggression. To combat barriers, parents described establishing routines, moderating access (i.e., shutting down internet and no device in bedroom), verbal priming, negotiating, and offering soothing/coping strategies. We will outline three key findings that may be considered for future research and interventions with this population.

Managing Screen Time Poses Unique Challenges

Nearly all parents discussed the challenges faced in managing screen use and reported that they felt their child received too much screen time. Excessive screen time levels increase children's risk of obesity, as they decrease opportunities for physical activity.³⁰ However, perhaps especially troubling children with N/MHD is that increased screen time is also associated with reduced psychological well-being,³¹ slowed learning,³² and reduced cognitive development.³³

However, based on parent-reported barriers, reducing screen use may not be actionable without behavioral supports in place. Parents reported concerns about physical aggression and major conflict and thus understandably desired more support to respond and prepare their child for changes in rules. Psychiatric and behavioral health practitioners may be specially equipped to help parents safely reduce or balance screen time for children with N/MHD who may rely on screens for calming purposes or struggle to limit media use at meals or before bedtime.³⁴ Future research should explore ways to assess and address such concerns, especially in their potential impact on physical and mental health of both children and parents.

Combining Clear Routines with Soothing May Yield Success

Parents who reported success in promoting both sleep and balanced screen time indicated that pairing clear routines with coping options to soothe children worked best. Some routines were typical of current best practices, such as a regular bedtime and general limits on screen time and access.³⁵ Multiple parents also kept sleep routines consistent on all 7 days of the week, as the variability in bedtime on weekends proved too disruptive for their children. Many parents who reported success also seemed to pair structure and boundaries with allowing children some autonomy (i.e., choosing music before bedtime and negotiating limits).

Parents Are Seeking Sleep Solutions

Although sleep disturbances are common among children with N/MHD,^20,36–38 parents in our study expressed distress about the lack of options to address sleep challenges. Many parents described dozens of attempted methods to manage sleep, with no success. Parents indicated that their child's poor sleep ultimately caused a cascade effect where other obesity-related behaviors (i.e., balanced eating, energy for physical activity, and motivation to move beyond a screen) became more challenging, consistent with existing literature.³⁹ In addition, poor sleep also impacted the family's overall quality of life. Parents reported needing to co-sleep with their children as a last resort when they felt no other options were available. In the literature, co-sleeping appears to be more common among older children with N/MHD and may also be associated with poorer quality sleep for both children and adults.⁴⁰

Future Directions

It may be prudent for any interventions related to obesity for children with N/MHD to consider intentionally addressing sleep problems through multiple approaches. Since children with N/MHD are at an increased risk of physiological disruptors of sleep,⁴¹ in addition to anxiety-reducing strategies and behavioral approaches, parents should also be informed about available therapeutic or pharmacological options. Peer support or ongoing problem-solving from a professional may also prove helpful, as the few parents with success described trying multiple strategies before finding one that worked.

Outside of the home, clinical settings are also an essential arena for addressing sleep and media use in children with N/MDH as a pathway to reduce obesity risk. In 2020, the Healthy Weight Research Network, a national research network of pediatric obesity and autism experts, published specific recommendations for managing overweight and obesity in children with autism spectrum disorder.⁴² A unique aspect of these recommendations was that they emphasized sleep as a key symptomology to examine and address. Increasing visibility of such guidelines while also enhancing health care professionals' capacity to counsel and coach parents would be an important step in improved overall care for N/MHD.

There is hope for families, as recent interventions utilizing behavioral supports, some even delivered through telehealth, have shown some success in helping children sleep more comfortably on their own.^43,44 However, most of this study focused primarily on children with autism or neurodevelopmental disabilities. Future study will be needed to translate existing research to determine intervention efficacy for children with mental health disorders.

Strengths and Limitations

Given the small sample size of predominantly white families, these findings are not generalizable to all children with N/MHD. In addition, participants were identified through a therapeutic day school in Massachusetts, and thus children may have different barriers/challenges than children in mainstream school settings and other regions. The study's strengths include the richness of data, and the focus on sleep and screen time, obesity-related behaviors infrequently discussed in the literature for this population of children.

Conclusions

Parents of children with N/MHD face unique challenges promoting sleep and balanced screen time for their children. Given these two behaviors impact both weight status and mental health, future interventions should examine ways to support parents in reducing conflict while promoting health. Effective programs must identify practical ways to address barriers, equip parents with behavioral tools to manage resistance with coping and soothing techniques, and acknowledge the importance of healthy sleep hygiene habits for children and their parents. Since each child is unique, families will likely benefit from interdisciplinary approaches that utilize positive framing and personalized problem-solving.

Footnotes

Authors' Contributions

K.K.D. and A.B. conceptualized the study and collaboratively developed the interview guide with input from R.K. K.K.D. provided project oversight while A.B. implemented recruiting. K.K.D., A.B., and R.K. conducted interviews, and worked collaboratively with R.E.B. to code and analyze data. R.E.B. wrote the article. A.B., K.K.D., and R.K. provided article review and editorial feedback. All authors read and approved the final article.

Funding Information

This study was made possible by a generous grant from the Lee Kum Sheung Center for Health and Happiness at Harvard T.H. Chan School of Public Health.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

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