PROJECT WORK

ENHANCE SLEEP CYCLE IN CHILDREN WITH ATTENTION

DEFICIT HYPERACTIVITY DISORDER – AN EXPERIMENTAL
STUDY
SUBMITTED TO DIVISION OF PHYSICAL MEDICINE AND
REHABILITATION, ANNAMALAI UNIVERSITY, ANNAMALAI NAGAR,
IN PARTIAL FULFILLMENT OF REQUIREMENTS FOR THE DEGREE OF
BACHELOR OF OCCUPATIONAL THERAPY

OCCUPATIONAL THERAPY 44 - PROJECT

SEPTEMBER – 2024

SUBMITTED BY
M. RADHA SONALI

FINAL YEAR BOT

DIVISION OF PHYSICAL MEDICINE AND REHABILITATION

RAJAH MUTHIAH MEDICAL COLLEGE AND HOSPITAL
ANNAMALAI UNIVERSITY
ANNAMALAI NAGAR – 608002
 DIVISION OF PHYSICAL MEDICINE AND REHABILITATION
RAJAH MUTHIAH MEDICAL COLLEGE AND HOSPITAL

ANNAMALAI UNIVERSITY,
ANNAMALAI NAGAR-608 002

OCCUPATIONAL THERAPY 44 - PROJECT

REGISTER NO: 067211011

This is to certify that this project is a bonafide record work done by

M. RADHA SONALI Final year B.O.T in partial fulfillment of the requirements for

the degree of Bachelor of Occupational therapy and submitted to Annamalai

University.

DURING THE YEAR SEPTEMBER - 2024

PROJECT GUIDE HOD i/c OCCUPATIONALTHERAPY

INTERNAL EXAMINER EXTERNAL EXAMINER

 ACKNOWLEDGEMENT
First and foremost, I would like to thank and praise the GOD for his grace
and blessings.

I humbly submit my respect and thanks to Dr. C. THIRUPATHI, Special

officer cum DEAN, Faculty of Medicine and RMMCH for providing an
opportunity to do this study.

I am grateful to Dr. N. JUNIOR SUNDERESH M.S., FRCS., FACS.,

Medical superintendent, HOD (i/c) of Radiology and Imaging Science,
Government Cuddalore Medical College and Hospital (Erstwhile RMMCH), for
granting permission to conduct the study.

I pay my deep sense of gratitude to Dr. DHANPAL SINGH, M.S.

Ortho, Professor and Head of Department, Division of PMR, RMMCH for his
valuable suggestions during the study period.

I wish to express my sincere respect and deepest gratitude to my Guide

Dr. G. SRIVIDYA, Head of the Department, Department of Occupational
Therapy, Physical Medicine and Rehabilitation, this work would not have
become successful without her guidance, support and encouragement. Under
her guidance I successfully overcame many difficulties and learned a lot.

In addition, I would like to thank the following faculty members of

Occupational Therapy Dr. G. SUGANYA, Dr. K. KALAICHANDRAN, Registrar
Department of Occupational Therapy, Mr. K.ANANDHAKRISHNAN,
Mr. A. MOHANRAJ, Mrs. I.THENMOZHI, Mrs. M.MANOSELVI, Department of
Occupational Therapy Physical Medicine and Rehabilitation, RMMCH.

It is pleasure to acknowledge that debt I owe to Division of PMR

Occupational therapy and Dr. P.PUNNIYA MOORTHI, Sumathy occupational
therapy center - cuddalore for giving permission to conduct my study with
ADHD in her children.

I would like to thank all my samples and their parents, who have
participated and co - operated in this study.

I offer my special thanks to my friend Mr M.SURENDIRAN MOORTHY,

Ms. S. YAZHINI, Ms. G. MANISHA, Ms. C. BAVYA, Mr. R. GOKULRAJ for
helping me to complete the project.
 I must express my very profound gratitude to my Parents
Mr. K.MOHANDOSS, Mrs. M. MEENA, Mr. M. HARIKARASUDHARSAN,
Mr. T. MOHANAUDHAYAKUMAR for providing me with unfailing support
and continuous encouragement throughout my years of study.

I want to extend my deepest thanks to my brother, Mr. R.RAJA RAMU and

my sisters, Miss. SUBALAKSHIMI, Miss. DEEPIKA, Miss. SUGANTHI for their
incredible support and encouragement throughout this journey. Their constant
belief in me have been a cornerstone of my success.

RADHA SONALI .M

(FINAL YEAR B.O.T)

 CONTENT

S.NO CHAPTERS PAGE

NO
ABSTRACT
1) INTRODUCTION 1
2) NEED FOR THE STUDY 7
3) REVIEW OF LITERATURE 8
4) METHODOLOGY 13
5) DATA ANALYSIS 15
6) RESULT 17
7) DISCUSSION 18
8) LIMITATIONS & RECOMMENDATIONS 20
9) CONCLUSION 21
10) BIBILIOGRAPHY 22
APPENDICES
ENHANCE SLEEP CYCLE IN CHILDREN WITH ATTENTION
DEFICIT HYPERACTIVITY DISORDER

ABSTRACT

BACKGROUND: Sleep disturbances are frequently associated with attention

deficit hyperactivity disorder (ADHD) .It is a neurobehavioral abnormality that
commonly occurs among the children. Poor sleep quality and delayed bedtime can
result in lack of concentration, changes in behavior and Physical health.
AIM: The aim of the study is to improve the sleep cycle in children with attention
deficit hyperactivity disorder by using occupational therapy neurophysiological
frame of reference – Roods approach
OBJECTIVE: To improve sleep cycle by Neutral warmth, weighted blankets, by
using occupational therapy neurophysiological frame of reference – Roods
approach. Weighted blankets to target children’s individual needs in connection
with sleep and daytime functioning.
METHODOLOGY:
A total of 19 samples of diagnosed ADHD children the selected for experimental
study based on selection criteria. Pretest and posttest assessment was done using
children’s sleep habits questionnaire to determine the level sleep pattern. Neutral
warmth technique was given as therapy for 20minutes each children over a period
of 12 weeks (Thrice a day).

TOOLS: Children sleep habit questionnaire

RESULTS: This Result shows significant improvement in sleep pattern in

diagnosed ADHD.

Paired 't' test was used to compare the pre -test(55.7) and post - test
values(52.5) of participants with sleep disturbances according to the score in
'CHIDREN'S SLEEP HABITS QUESTIONNAIRE SCALE'
 This showed that there was a significant improvement in post score
compared to pre score resulting in improvement in sleep pattern (P value <0.05).

FRAME OF REFERENCE: Neuro physiological frame of reference - ROODS

APPROACH

CONCLUSION:

This study concluded that neutral warmth technique and weighted blanket
are effectively in improving the pattern of sleep in diagnosed ADHD.

KEY WORDS: Sleep disorder, weighted blankets, deep pressure, swiss ball,
Roods approaches, Nocturnal sleep disturbances, Neutral warmth, activity of daily
living, sleep disturbances.
 CHAPTER - I

INTRODUCTION

Attention deficit disorder (ADD) is a syndrome found in 3 percent

of preadolescent children. It has been recognized for almost 30 years and
is identified by a variety of names: hyperactivity, hyperkinesis,
hyperkinetic impulsive disorder, or if hyperactivity is not evident,
undifferentiated attention deficit disorder. Here the terms attention deficit
disorder and hyperactivity will be used interchangeably.

Children with attentional deficits have trouble at home, at school,

and even at play.

The primary problem of children with ADHD are their inability to

sustain attention and control theira impulses. The attentional difficulties
interfere with completion of school work and household tasks. These
children cannot keep themselves entertained at play for prolonged
periods, and they do not seem to listen to others. Their impulsivity results
in careless school work and irritability or aggression towards others.

The American Psychiatric Association's Diagnosis and

Statistical Manual of Mental Disorders (DSM III-R) provides the
following criteria for diagnosing attention deficit hyperactivity
disorder in children:

A disturbance of atleast 6 months during which at least eight of the

following are present

1. Often fidgets with hands or feet or squirms in seat (in adolescent may
be limited to subjective feelings of restlessness)

2. Has difficulity remaining seated when required to do

1
 3. Is easily distracted by extraneous stimuli

4. Has difficulty awaiting turn in games or group situations

5. Often blurts out answer to questions before they have been

completed.

6. Has difficulty following through on in structions from others,

example: fails to finish chores

7. Has difficulty sustaining attention in tasks or play activity.

8. Often shifts from one uncompleted activity to another

9. Has difficulty playing quietly

10. Often talks excessively

11. Often interrups for intrudes on others e.g., butts into other children's
games

12. Often does not seem to listen to what is being said to him or her

13. Often loses things necessary for tasks or activities at school or at

home (e.g.,toys, pencils, books, assignments)

14. Often engages in physically dangerous activities without considering

possible consequences (not for the purpose of thrill- seeking), e.g., runs
into street without looking

B. Onset before the age of 7

C. Does not meet the criteria for a pervasive developmental disorder

2
CAUSES

ADHD is more common in boys (1:5) than girls (1:9)

Congenital physical anomalies in children with ADD

Some have mild to moderate electroencephalogram (EEG)

abnormalities

5 percent of hyperactive children have diagnosable neurological

disorders

Children with aggresive behaviour are more likely to come from

low socioeconomic status.

Attention, arousal, and inhibition

Attention, arousal, and inhibition are all inter -related component

of information processing.

Attention is the process by which an individual receives, selects,

and processes information about the environment.

Arousal is the physiologic and psychology state of readiness to

process information.

Attention and arousal are intricately related: Arousal activates

attention and attention increases arousal.

Inhibition is the neural process in which one part of the nervous

system prevents another part from overacting to sensory inputs

Modulating is" the process of increasing or reducing a neural

activity to keep that activity in harmony with all the other functions of the
nervous system"

3
 Hyperactive children obviously have problem with attention, but
the nature of the problem is not clear. Parents and teachers complain that
they do not listen, are careless with school work, do not obey, and do not
pay attention. However, the same children who have trouble sustaining
attention in the classroom can watch TV for hours. An important goal of
research in ADHD is identifying which aspects of attention are impaired.

INSOMNIA

Insomnia is ―a persistent difficulty with sleep initiation, duration,

consolidation, or quality that occurs despite adequate opportunity and
circumstances for sleep, and results in some form of daytime impairment‖
(American Academy of Sleep Medicine, 2014). DSM-5 integrates
pediatric and developmental criteria and replaces primary insomnia with
the diagnosis of insomnia disorder, to avoid the primary/secondary
distinction when this disorder co-occurs with other conditions. DSM-5
introduced a duration criterion (more than 3 ‗bad nights‘ per week for the
last 3 months).

Prevalence of pediatric insomnia is estimated at about 1% to 6% in

general pediatric populations, with a much higher prevalence in children
with neurodevelopmental and chronic medical and psychiatric conditions.
When bedtime resistance and disruptive nighttime awakenings are
included, the prevalence of sleep-disrupted behavior approaches 25% to
50% in preschool children. Conversely, psychiatric symptoms have been
reported in almost 50% of children with persistent insomnia.

It has been proposed that persistent insomnia may also represent an

early sign of emotional distress in susceptible children with poor sleep
homeostasis. He term behavioral insomnia of childhood refers to sleep
diiculties that result from inappropriate sleep associations or inadequate

4
parental limit setting. he diagnosis of sleep-onset behavioral insomnia
relies on the presence of maladaptive and inappropriate sleep associations
such as rocking, watching television, and falling asleep in the parents‘
bed. He child is usually unable to fall asleep in the absence of these
conditions at both bedtime and on waking up during the night. Inadequate
parental limit setting can also result in a form of behavioral insomnia
characterized by a delay in sleep onset secondary to a child‘s refusing to
go to bed or stalling.

SLEEP DISTURBANCES IN CHILDREN WITH ATTENTION

DEFICIT HYPERACTIVITY DISORDER

There has been an increasing interest in sleep problems associated

with ADHD (Cortese et al, 2009; Cortese et al, 2013). Sleeping diiculties
in these children are of relevance because:

• Sleep disturbances may be a source of distress for the child and the
family

• Sleep problems may worsen ADHD symptoms as well as associated

emotional disorders

• Quantitative or qualitative alterations of sleep may cause problems with

mood, attention, and behavior,

• Sleep disturbances may mimic ADHD symptoms in children

misdiagnosed with ADHD.

Therefore, symptoms of inattention, hyperactivity and impulsivity

may be improved or even eliminated by treating the primary sleep
disorder. A meta_analysis on sleep in children diagnosed with ADHD
found that children or their parents reported bedtime resistance,
sleep-onset diiculties, night awakenings, diiculty waking up in the

5
morning, sleep breathing problems, and daytime sleepiness signiicantly
more often than healthy comparison individuals (Cortese et al, 2009).
Although no sleep problem speciic to ADHD has been found, the most
commonly reported is ‗diiculty falling asleep‘.

Causes of sleep problems in children with ADHD include:

• One or more speciic sleep disorders, such as behaviorally-based

insomnia, circadian rhythm sleep disorder, or restless legs syndrome

• Poor sleep practices (e.g., use of electronics before bedtime)

• Psychiatric comorbidities (e.g., mood/anxiety disorders)

• Associated medical conditions and their treatment (e.g., asthma,

obesity).

NEUROPHYSIOLOGICAL FRAME OF REFERENCE – ROODS

APPROACH

The neurophysiological frame of reference in neuroscience may

refer to the use of spatial and temporal coordinates to uncover the
mechanisms of episodic memory and understand the hippocampal
system.

In neurophysiology, the "frame of reference" typically refers to the

perspective or context within which neural activity is understood or
interpreted. This can include several different approaches or viewpoints:

1. Anatomical Frame of Reference:

- Focuses on the physical structure of the nervous system, including

specific brain regions, neural pathways, and connections. For example,
understanding how different parts of the brain like the cortex, thalamus,
and spinal cord interact to produce movement.
6
2. Functional Frame of Reference:

- Concentrates on the functional aspects of the nervous system, such as

how specific neural circuits are involved in processes like perception,
cognition, motor control, or emotion. It‘s about mapping functions to
specific neural structures.

3. Electrophysiological Frame of Reference:

- Relates to the electrical activity of neurons, often measured through

techniques like electroencephalography (EEG) or intracranial recordings.
This frame of reference focuses on understanding how electrical signals
represent information and contribute to neural processing.

4. Behavioral Frame of Reference:

- Looks at the relationship between neural activity and behavior,

examining how changes in neural function correspond to changes in
observable behaviors or psychological states.

5. Computational Frame of Reference:

- Uses mathematical models and simulations to understand how

neurons and networks of neurons process information. This approach
often involves theories from information processing and machine
learning.

6. Pathophysiological Frame of Reference:

- Focuses on how deviations from normal neural activity contribute to

disease. This includes studying the neurophysiological basis of disorders
like epilepsy, Parkinson‘s disease, or multiple sclerosis.

7
7. Developmental Frame of Reference:

- Examines how the nervous system develops from embryonic stages

through adulthood, considering how changes over time affect function
and structure.

ROOD'S APPROACH

Rood‘s approach is a neurophysiologic and developmental

treatment approach that was developed by Margret Rood to improve tone
of muscles (both flaccid and spastic).

PRINCIPLES

 Utilization of controlled sensory stimulation.

 Utilization of developmental sequences.

 Utilization of an activity to demand a purposeful response.

 Normalization of tone and muscular responses are achieved via

controlled sensory stimulation.

 Sensor motor control is developmentally based.

 Muscular responses of agonists, antagonists and synergists are

believed to be reflexively programmed according to purpose or
plan.

 Repetition/practice is necessary for motor learning.

8
 CHAPTER - II

NEED FOR THE STUDY

Children with ADHD are more likely to experience shorter sleep

time, problem in falling as sleep and have a risk of developing a sleep
disorder and also have a poor quality of sleep and later bed time. Sleep
problem can lead to forgetfulness and difficulty concentrating during the
day time. Many children with the ADHD have impact on behavioural
problem, learning disorders, anxiety and depression. Many studies focus
on lack of attention hyperactivity impulsivity but they missed out to focus
on sleep problems among the ADHD .This will also have risk on increase
in hyperactivity and impulsivity. So, I took responsibility to focus on
sleep problems by using occupational therapy neurophysiological frame
of reference roods approach. This will enhance the overall quality of life
for both children with ADHD and their families and give positive impact
on their mood regulation, cognitive functioning and improved outcomes
in academic performance and day to day activities.

9
 CHAPTER - III

REVIEW OF LITERATURE

1. ZAHRA KESHAVARZI et al.,(2014) In a randomized case -

control trial with 10 - years olds suffering from ADHD sleep
disturbance. Hence, this study concluded that training and
monitoring parents of children with ADHD in regulating and
supervising children, sleep schedules leads to positive changes in
the emotions, behavior and social lives of these children.

2. HARRIET HISCOCK et al., (2019) Impact of behavioural

intervention, delivered by pediatricians or psychologists, on
sleep problems in children with ADHD. Hence, this study
concluded that the low cost brief sleep intervention is effective in
improving sleep problems when delivered by community
clinicians.

3. JANE NIKLES et al.,(2020) The effectiveness of sleep hygiene

in children with ADHD. Hence this study concluded that there is
growing evidence to support the use of sleep hygiene interventions
to improve sleep quality in children with ADHD and sleep
disturbance.

4. VEDRANA BOLIC BARIC et al.,(2021) The effect of weighted

blankets on sleep and everday activities. A retrospective followup
study of children and adults with attention deficit hyperactivity
disorder. Hence this study concluded that 12 weeks therapy
programme on weighted blanket and it showed positive impact on
falling asleep. This study indicates that weighted blanket improved
Morning /Evening routine.

10
5. RISMA DUI NUR PRATIWI et al.,(2021) The intervention for
sleep disorder in children with attention deficit and
hperactivity disorder. Hence, this study shows the most
comprehensiveness with a high level of ease of implementation
was BPT.

6. INGRID LARSSON et al.,(2021) The effect of weighted

blankets "Impact on children with attention deficit/
hyperactivity disorder and sleep problem”. Hence, this study
that children with ADHD and sleep problem who participated in an
intervention with weighted blankets. When using weighted
blankets the children achieved satisfactory sleep, Including
improved sleep onset latency, sleep continuity, and sleep routines.
The overall well-being among children was also improved.

7. MAYA K MALKANI et al., (2022) The effect of behavioural

sleep interventions for children with ADHD. Hence this study
support the use of behavioral sleep interventions for school - aged
children with ADHD. Finding suggest that brief, individualized
intervention may be more effective than standardized.

8. MARIA LONIS et al.,(2023) The effect of using weighted

blankets among children with ADHD and sleep difficulties.
Hence, this study shows that the children experienced with
weighted blankets improved their sleep, sleeping pattern and the
balance between activity and sleep but also improved emotional
regulation and daily functioning.

9. L BOND et al.,(2023) The intervention for sleep problems in

children and adolscents in an attention deficit hyperactivity
disorder. Hence, this study has demonstrated an association

11
 between more sleep problems and ADHD severity. These findings
highlight the need for both effective ADHD treatments to ensure
optional sleep in young people as well as effective interventions for
sleep problems to prevent worsening of ADHD symptoms.

10. JIEYU et al.,(2023) The effect of weighted blankets on sleep

and related disorder amoung the ADHD children. Hence, this
study concluded that weighted blankets could effectively improve
sleep quality and alleviate negative emotions and daytime
symptoms in patients with Attention Deficit Hyperactivity
Disorder.

12
 CHAPTER - IV

METHODOLOGY

AIM:

The aim of the study is to improve the sleep cycle in children with
attention deficit hyperactivity disorder by using occupational therapy
neurophysiological frame of reference – Roods approach

OBJECTIVE:

To improve sleep cycle by Neutral warmth, weighted blankets, by

using occupational therapy neurophysiological frame of reference –
Roods approach. Weighted blankets to target children‘s individual needs
in connection with sleep and daytime functioning.

STUDY SETTING: Sumathy Occupational Therapy Centre, Cuddalore.

STUDY DESIGN: Quasi experimental study.

SAMPLE SIZE: 19 diagnosed ADHD children.

MATERIAL REQUIRED:

 Weighted blankets

 Swiss Ball

SELECTION CRITERIA

INCLUSION CRITERIA:

 Diagnosed ADHD child under the age of 6-12 years.

 Both gender were included for this study

 ADHD with nocturnal sleep disturbances

13
EXCLUSION CRITERIA:

 children with neurological disorder

 children with cardiovascular disease

TOOLS: Children sleep habit questionnaire

STUDY PROCEDURE

1. As total number of 19 samples based on inclusion criteria were

selected for the study.

2. A written informed consent form was received from the parent's,

prior to the intervention.

3. "CHILDREN'S SLEEP HABITS QUESTIONNAIRE was

distributed to parents".

4. Prior to the study instructions was given to the parents about

Treatment procedure in vernacular language.

5. Neutral warmth technique was taught to parents.

6. Instructions was given to parents as Take a weighted blankets and

spread the blanket on the floor and the child lie down on one
corner of the blanket in the supine position.

7. Roll the blanket tightly around him/her (should cover from

shoulder to feet).

8. Deep pressure was given to child using Swiss ball.

9. Finishing of this technique, parents are asked to cover the child

with weighted blankets for better sleep.

14
INTERVENTION

1. Neutral warmth technique was given to diagnosed ADHD child.

Neutral warmth acts through stimulating the thermoreceptors and
activating parasympathetic responses. It is one of the calming
technique and most commonly used methods to inhibit postural
tone and muscle activity for diagnosed ADHD child.

2. Usually 10-20 minutes is sufficient duration to produce an effect.

3. Spread the bed sheet or blanket on the floor and have the child lie
down on one corner of the blanket in the supine position and roll
the blanket tightly around him/her (should cover from shoulder to
feet).

4. Swiss ball is used to give pressure on wrapped child.

5. Finishing of this technique, parents are asked to cover the child

with weighted blanket for better sleep.

6. Using weighted blanket is one of the best ways to enjoy better

sleep, particularly for those with condition such as ADHD.

7. Weighted blankets soothes the body so that it is easier to fall asleep

and get deep sleep.

8. Weighed blankets use deep touch pressure (DTP) to relax the

nervous system. It causes your brain to release serotonin, which
helps you feel calm.

15
OUTCOME MEASURES

The CSHQ is a parent -rated questionnaire comprised of 33

scored questions .Each scored question is rated on a 3- point scale as
occuring, usually (5-7 times within the past week), sometimes (2-4 times
within a past week), rarely (never or 1 time within the past week).

A number of items on the questionnaire are reverse scored, so that

higher scores consistently indicate problem.A total sleep disturbance
score of over 41 indicates a paediatric sleep disorder.

16
 CHAPTER - V

DATA ANALYSIS

STATISTICAL ANALYSIS

In this study, data entry was performed using Microsoft Excel.

Descriptive statistics, including mean and standard deviation, were
calculated for continuous variables. A paired sample t-test was applied to
compare pre - and post - score of CHILDREN'S SLEEP HABITS
QUESTIONNAIRE.

PRE - POST SCORE ANALYSIS OF CHILDREN'S SLEEP

HABITS QUESTIONNAIRE SCALE

n mean Mean Standard t value p value

difference deviation
PRE-TEST 19 55.7 2.2 13.01 1.73 0.05
POST 19 52.5 2.2 11.5 2.1 0.05
TEST

The table represents the pre and post score data analysis of
CHILDREN'S SLEEP HABITS QUESTIONNAIRE SCALE. As it
mention above, total number of participants took part in this study is 19.
The p-value(0.05) for the pre and post score is significiant. The mean
difference between the pre and post score is 3.

17
BAR GRAPH

This graph represent mean value of pre score data and post score
data

MEAN OF PRE AND POST TEST

56 55.7
55.5
55
54.5
54
53.5
53 52.5
52.5
52
51.5
51
50.5
pre test post test

18
 CHAPTER – VI

RESULT

The study was conducted to improve pattern of sleep in children

with Attention Deficit Hyperactivity Disorder.

The pre-test and post test scores have been calculated and
performed paired‘t‘ test for the collected data. The bar graph represents
the mean value of pre and post.

Paired 't' test was used to compare the pre -test(55.7) and post - test
values(52.5) of participants with sleep disturbances according to the score
in 'CHIDREN'S SLEEP HABITS QUESTIONNAIRE SCALE'

This showed that there was a significant improvement in post score

compared to pre score resulting in improvement in sleep pattern
(P value <0.05).

19
 CHAPTER - VII

DISCUSSION

Children with diagnosed ADHD who are all suffered from sleep
difficulties have described experiences of using neutral warmth technique
occupational therapy neurophysiological the frame of reference (ROODS
APPROACH) and weighted blankets. According to my results children
commiting to neutral warmth technique and weighted blanket can
improve their emotional regulation and change their pattern of sleep. The
children described their ability to commit to the neutral warmth and
weighted blanket as being dependent on parental attitudes towards their
children.

For this study, I choosed clients of sumathy occupational therapy

centre at Cuddalore was included as participants. I assessed 25 diagnosed
ADHD among 19 children were suffered from sleep difficulties.
Assessment was taken to parents about their children through
CHILDRENS SLEEP HABITS QUESTIONNAIRE SCALE. I translated
the scale in tamil for parents convinence. During an assessment, parents
complaints that their children roaming around the bed, playing with toys,
scribbling in their notes. Samples were identified to have sleep
disturbances according to children's sleep habits questionnaire scale. The
pretest score was noted down .the parents were instructed to give neutral
warmth technique using weighted blanket before the child go the bed.
The parents were also instructed to cover the childs body using weighted
blanket which will additionally enhance sleep. After that neutral warmth
and weighted blankets was given as intervention. The post test score was
noted down. In observation the score goes down after practicing neutral
warmth technique and weighted blankets which signifies the

20
improvement in sleep pattern level in children with ADHD.

The overall findings demonstrated that children with ADHD stated

that using neutral warmth technique and weighted blankets during sleep,
improved their ability to fall asleep, which showed positive trends
towards an increase in total amount of sleep per night as well as a slight
decrease in time to fall asleep. This is particularly important as
insufficient sleep has a crucial impact on performance in daily activity
such as education, activity of daily living, work, play, leisure, and social
participation. However, It is possible that these findings are related to a
perception of improved sleep brought about by improved sleep hygiene
consist of a set of behavioral, environmental, or cognitive modification to
improve sleep (i.e. Restrictions of electronic media use, modification of
bedtime and bedtime routines, restriction of caffeine use, modification to
bedroom or sleeping environment),which are often the first line treatment
recommended.

21
 CHAPTER - VIII

LIMITATIONS & RECOMMENDATIONS

LIMITATION

This study was conducted on a limited size of sample.

This study was conducted in limited duration.

RECOMMENDATION

Study can be done on larger sample size.

Study can be done on longer duration.

Neutral warmth can studied on autism.

Study can improve bed time routine, it also encourage day time
activity

Study can promote healthy eating habits

22
 CHAPTER - IX

CONCLUSION

The result of this study concluded that neutral warmth technique

and weighted blanket is an effective method to enhance pattern of sleep in
ADHD child.

Which will enhance the performance in daily living, work, play,

leisure and social participation.

23
 CHAPTER – X

BIBLIOGRAPHY

REFERENCE

1. Bolic Baric V, Skuthälla S, Pettersson M, Gustafsson PA,

Kjellberg A. The effectiveness of weighted blankets on sleep and
everyday activities–A retrospective follow-up study of children and
adults with attention deficit hyperactivity disorder and/or autism
spectrum disorder. Scandinavian Journal of Occupational Therapy.
2023 Nov 17;30(8):1357-67.

2. Larsson I, Aili K, Nygren JM, Jarbin H, Svedberg P. Parents‘

experiences of weighted blankets‘ impact on children with
attention-deficit/hyperactivity disorder (ADHD) and sleep
problems—a qualitative study. International journal of
environmental research and public health. 2021 Dec
8;18(24):12959.

3. Pratiwi RD, Fitri SY, Mulya AP. The interventions for sleep
disorders in children with attention deficit and hyperactivity
disorder: A narrative review. Open Access Macedonian Journal of
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4. Yu J, Yang Z, Sun S, Sun K, Chen W, Zhang L, Xu J, Xu Q,

Liu Z, Ke J, Zhang L. The effect of weighted blankets on sleep
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Kirov R, Gerber M, Holsboer-Trachsler E, Brand S. In a
randomized case–control trial with 10-years olds suffering from
24
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psychological functioning improved during a 12-week
sleep-training program. The world journal of biological psychiatry.
2014 Dec 1;15(8):609-19.

6. Hiscock H, Mulraney M, Heussler H, Rinehart N, Schuster T,

Grobler AC, Gold L, Bohingamu Mudiyanselage S, Hayes N,
Sciberras E. Impact of a behavioral intervention, delivered by
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ADHD: A cluster‐randomized, translational trial. Journal of Child
Psychology and Psychiatry. 2019 Nov;60(11):1230-41.

7. Lönn M, Aili K, Svedberg P, Nygren J, Jarbin H, Larsson I.

Experiences of using weighted blankets among children with Adhd
and sleeping difficulties. Occupational Therapy International.
2023;2023(1):1945290.

8. Pratiwi RD, Fitri SY, Mulya AP. The interventions for sleep
disorders in children with attention deficit and hyperactivity
disorder: A narrative review. Open Access Macedonian Journal of
Medical Sciences. 2021 Nov 25;9(T6):164-72.

9. Malkani MK, Pestell CF, Sheridan AM, Crichton AJ,

Horsburgh GC, Bucks RS. Behavioral sleep interventions for
children with ADHD: A systematic review and meta-analysis.
Journal of attention disorders. 2022 Dec;26(14):1805-21.

10. Nikles J, Mitchell GK, de Miranda Araújo R, Harris T,

Heussler HS, Punja S, Vohra S, Senior HE. A systematic review
of the effectiveness of sleep hygiene in children with ADHD.
Psychology, health & medicine. 2020 Apr 20;25(4):497-518.

25
 APPENDIX - I

Consent form

ENHANCE SLEEP CYCLE IN CHILDREN WITH ATTENTION

DEFICIT HYPERACTIVITY DISORDER

Details of the Investigator –

M.Radhasonali, BOT Final Year,

Division of Physical Medicine and Rehabilitation,

Rajah Muthiah Medical College and Hospital, Annamalai Nagar,

Chidambaram.

I…………………………. voluntarily consent to take part in this

project study. I had fully discussed and understood the purpose and
procedure. The study and its effects had been explained to me in a
language that I understand. I had been given time to ask any questions
about the study and all my questions had been answered to my
satisfaction.

Name of the participant -

Signature with date

26
 APPENDIX – II

MASTERCHART

S.NO NAME AGE GENDER PRETEST POSTTEST

1 S 8 female child 67 60
2 N 6 male child 40 40
3 A 6 male child 57 59
4 J 7 male child 40 42
5 K 8 male child 82 79
6 A 7 male child 60 58
7 A 8 female child 52 48
8 H 6 male child 40 41
9 M 6 male child 63 59
10 M 7 male child 42 42
11 J 8 female child 53 50
12 A 8 male child 63 60
13 P 6 female child 50 47
14 Y 6 female child 45 42
15 K 7 male child 65 60
16 M 10 female child 65 60
17 J 6 female child 40 40
18 M 6 male child 56 54
19 K 5 male child 50 46

27
 APPENDIX – III

CHILDREN’S SLEEP HABITS QUESTIONNAIRE

28
 TAMIL TRANSLATION

குறந்தைகரின் தூக்க பறக்கம் ககள்லித்ைாள்

பப஬ர்:

ல஬து:

உமங்கும் கே஭ம்

குறந்தை தூங்கும் கே஭த்தை எழுதுங்கள்: ________________________

1) குறந்தை இ஭லில் ஒக஭ கே஭த்ைில் படுக்தகக்குச் பெல்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

2)படுக்தகக்குச் பென்ம 20 ேி஫ிடங்கரில் குறந்தை தூங்கு஫ா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

3)குறந்தை ைனி஬ாக படுக்தக஬ில் தூங்குகிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

29
4)பபற்கமார் அல்யது உடன்பிமந்ைலர்கள் படுக்தக஬ில் குறந்தை
தூங்குகிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

5)உங்கள் பிள்தர தூங்குலைற்கு அதம஬ில் பபற்கமார் கைதல஬ா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

6) உங்கள் குறந்தை தூங்கும் கபாது ெி஭஫ப்படுகிமைா?

(அழுகிமது, படுக்தக஬ில் இருக்க ஫றுக்கிமது)?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

7)உங்கள் குறந்தை இருட்டில் தூங்க ப஬ப்படுகிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

30
8)உங்கள் குறந்தை ைனி஬ாக தூங்க ப஬ப்படுகிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

தூக்க ேடத்தை

ஒவ்பலாரு ோளும் உங்கள் பிள்தர஬ின் லறக்க஫ான அரவு தூக்கம் :________

஫ணிகே஭ம் ஫ற்றும்_______ேி஫ிடங்கள்

9) உங்கள் குறந்தை குதமந்ை ஫ணிகே஭ம் தூங்குகிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

10) உங்கள் குறந்தைக்கு தூங்கும் கே஭ம் கபாது஫ானைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

11) உங்கள் குறந்தை தூங்கும் கே஭ம் ஒவ்பலாரு ோளும் ஒக஭ ஫ாைிாி஬ாக

இருக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

31
12)உங்கள் குறந்தை இ஭லில் படுக்தகத஬ ேதனக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

13)உங்கள் குறந்தை தூங்கும் கபாது கபசுகிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

14)உங்கள் குறந்தை அத஫ைி஬ின்மி உமக்கத்ைின் கபாது அைிக஫ாக

ேகர்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

15)உங்கள் குறந்தை தூங்கும் கபாது ேடக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

32
16) உமங்கும் கபாது உங்கள் குறந்தை கலறு படுக்தகக்கு ேகர்கிமைா?

(பபற்கமார், உடன்பிமந்ைலர்கள், முைலி஬ன)

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

17)உங்கள் குறந்தை தூக்கத்ைின் கபாது பற்கதர அத஭க்கிமைா அல்யது

கடிக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

18)உங்கள் குறந்தை ெத்ை஫ாக குமட்தட லிடுகிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

19) உங்கள் குறந்தை தூங்கும் கபாது சுலாெிப்பைில் ெி஭஫ம் உள்ரைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

33
20)உங்கள் குறந்தை தூக்கத்ைின் கபாது குமட்தட லிடுகிமைா ஫ற்றும் / உங்கள்
பிள்தர தூங்கும் கபாது மூச்சுத்ைிணமல் உள்ரைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

21) உங்கள் பிள்தரக்கு உமலினர்கள் கபான்ம கலறு இடத்ைில் தூங்குலைில்

ெிக்கல் உள்ரைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

22)உங்கள் குறந்தை இ஭லில் அயமல், லி஬ர்த்ைல் ஫ற்றும் அத஫ைி஬ற்ம

ேிதய஬ில் எழுந்ைிருக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

23)உங்கள் குறந்தை ப஬முறுத்தும் கனலில் லிறித்ைிருக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

34
இ஭லில் லிறிப்பு

24)உங்கள் குறந்தை இ஭லில் ஒரு முதம எழுந்ைிருக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

25)உங்கள் குறந்தை இ஭லில் ஒன்றுக்கு க஫ற்பட்ட முதம எழுந்ைிருக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

காதய லிறிப்பு

குறந்தை பபாதுலாக காதய஬ில் எழுந்ைிருக்கும் கே஭ம்:_____________

26) உங்கள் குறந்தை எந்ை உைலியும் இல்யா஫ல் காதய஬ில் எழுந்ைிருக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

27)உங்கள் குறந்தை எைிர்஫தம஬ான ஫னேிதய஬ில் எழுந்ைிருக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

35
28) உங்கள் குறந்தை பபாி஬லர்கள் அல்யது உடன்பிமந்ைலர்கரால்

எழுப்பப்படுகிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

29) உங்கள் பிள்தரக்கு காதய஬ில் படுக்தக஬ில் இருந்து எழுலைில் ெி஭஫ம்

உள்ரைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

30) உங்கள் குறந்தை காதய஬ில் சுறுசுறுப்பாக ஫ாம ேீண்ட கே஭ம் எடுக்கிமைா?

3 2 1
பபாதுலாக ெிய கே஭ங்கரில் அாிைாக
(5-7) (2-4) (0-1)

பகல் தூக்கம்

31)உங்கள் குறந்தை பகலில் கொர்லாக இருக்கிமைா?

கடந்ை லா஭த்ைில், உங்கள் பிள்தர ஫ிகவும் தூக்கத்ைில் இருந்ைா஭ா அல்யது

பின்லருலனலற்மின் கபாது தூங்கிலிட்டா஭ா:

36
32)பைாதயக்காட்ெி பார்க்கும் கபாது—

3
2
1 பைாடர்ந்து
ேன்மாக தூங்குகிமார்
தூங்குலைில்தய தூங்குகிமார்

33) லாகனத்ைில் பெல்லும் கபாது—

3
2
1 பைாடர்ந்து
ேன்மாக தூங்குகிமார்
தூங்குலைில்தய தூங்குகிமார்

37
APPENDIX – IV

38
 APPENDIX – V

PHOTO GALLARY

FIG – 1 EXPLANATION OF NEUTRAL WARMTH

TECHNIQUE TO PARENTS

Fig - 1a Fig - 1b

39
FIG – 2 PRACTICING OF NEUTRAL WARMTH
TECHNIQUE BY PARENTS

Fig - 2a Fig - 2b

Fig – 2c Fig – 2d

40
Fig – 2e Fig – 2f

Fig – 2g

41