Mini-KiSS Online: an Internet-based intervention program for parents of young children with sleep problems – influence on parental behavior and children’s sleep

Figures & data

Table 1 Demographic variables of the parents

Variable	Mothers (N = 52)	Fathers (N = 52)
Age, (years)
Range	22–41	25–60
Mean (SD)	32.17 (4.36)	35 (6.34)
Education, (number of persons)
Secondary general school	6	6
Intermediate school	12	14
Grammar school	14	8
University	20	20
Unknown	0	4
Employment, (number of persons)
Unemployed (intended)	30	0
Unemployed (unintended)	2	0
Part time	16	2
Full time	4	49
Unknown	0	1

Abbreviations: N, Number; SD, Standard Deviation.

Table 2 Content of Mini-KiSS Online training

Session	Contents	Methods
1. Psychoeducation and first steps	Information about day-night rhythm, sleep-cycle, sleep-duration, functions of sleep, sleep disorders, influencing factors on sleep, and daytime structure. Explanation about the use of bed-time-stories, imagination CDs and homework (eg, planning a new bedtime-ritual)	Psychoeducation 1(break/)Cognitive behavior therapy(break/)Imaginations/imaginative therapy
2. Educational behavior and sleep hygiene	Information about sleep hygiene (part 1), the relation of daytime behavior and sleep, the importance of educational behavior, learning behavior of children, token systems. how to use the stuffed leopard in a proper way, implementing educational rules and instructions of using the new imagination exercise and bedtime stories and how to create a personalized token system are further contents of this session	Psychoeducation II(break/)Behavior therapy(break/)reward systems(break/)Using imaginations for children
3. Crying and defiantness	Information about crying and appropriate tranquilization, reasons for crying, defiantness, aggressive behavior, intervention strategies for these topics, information about sleep environment (sleep hygiene part 2), new imagination exercise and bedtime stories	Psychoeducation III(break/)Cognitive behavior therapy Bedtime stories
4. Distress and relaxation	Information about the influence of distress and relaxation for parents on their educational behavior, how to use cognitive strategies, instruction to adopt special play-times for the child and relaxation times for the parents, new imagination exercise and bedtime stories	Cognitive behavior therapy Relaxation techniques Imaginations
5. Anxieties and feeling of security	Information about day and night anxieties of children, behavior and intervention strategies, implementing a feeling of security, information about the relation between sleep and feeding, relaxation and massage for children, systematic integration of the knowledge acquired from session one to five, new imagination exercise and bedtime stories	Cognitive behavior therapy Relaxation techniques Imaginations
6. Risk to comply and summarization	Information about the risk to comply and intervention strategies, typical pitfalls, calmness and attentiveness, summarization of useful strategies for the family, repetition of sleep hygiene (part 1)	Cognitive behavior therapy

Table 3 Most preferred contents (mean ≤ 2)

Session	Topic/information about	Mean (SD)
1	Human sleep	1.85 (0.92)
1	Sleep disorders and influencing factors	1.96 (0.82)
2	Relationship between daytime behavior and sleep at evening	1.54 (0.71)
2	Learning through consequences	1.85 (0.97)
2	Educational strategies for consequent behavior	1.76 (0.78)
2	Educating strategies for healthy sleep	1.96 (1.18)
2	Creative problem solving	1.96 (0.89)
3	Behavior strategies for handling crying and screaming situations	2.00 (1.10)
3	Defiance behavior	1.92 (1.20)
4	Parental distress/stress-worsening cognitions	1.96 (0.87)/1.73 (0.72)
4	Cognitive coping strategies against distress	1.73 (0.92)
4	Time and attention for and with the child	1.75 (0.74)
5	Feeling of security and anxiety	1.73 (0.87)
5	Anxieties in childhood	1.69 (0.79)
5	Intervention strategies for anxieties	1.88 (1.03)
5	Intervention strategies for feeling of security	1.85 (1.05)
5	The importance of structuring an intervention plan	1.92 (0.74)
6	The risk to comply	1.68 (0.95)
6	Calmness	1.68 (0.63)
6	Attentiveness/attention for everyday occurrences	1.71 (0.62)/1.80 (0.82)

Notes: Item values: 1 = was completely helpful for me, 2 = was rather helpful for me, 3 = I don’t know, 4 = was rather not helpful for me, 5 = was not at all helpful for me.

Abbreviation: SD, standard deviation.

Figure 1 Results of the acceptance assessment of Mini-KiSS Online Questionnaire for statements 1 to 3.*

Notes: *“The topics of the last training session appealed to me”; statement 2, “I was able to transfer the general information to my personal situation”; statement 3, “The last online-session motivated me to continue working on the sleep problem of my child.”

Figure 2 Results of the acceptance assessment of Mini-KiSS Online Questionnaire for statement 4.*

Notes: *Statement 4, “I have the feeling that the sleep situation of my child has improved.” **Significant differences (P = 0.01).

Table 4 Global statements about Mini-KiSS Online training

Statements	Mean (SD)
1. I believe that in the future I will be able to handle the sleep problem of my child	1.76 (0.78)
2. The Online training answered nearly all of my questions	2.52 (1.26)
3. The Online training helped me to better understand the sleep behavior of my child	1.83 (1.17)
4. I am glad that I participated in the Online training	1.64 (0.99)
5. I would recommend the Online training to other families with sleep problems	1.40 (0.82)
6. The questionnaires helped me to better understand the sleep problem	1.88 (1.20)
7. I was able to cope well with the organization of the Online training	1.80 (0.87)

Notes: Item values: 1 = completely applies to me, 2 = rather applies to me, 3 = I don’t know, 4 = rather doesn’t apply to me, 5 = doesn’t apply to me at all.

Abbreviation: SD, standard deviation.

Table 5 Results of the sleep behavior of the child: sleep diary

	Sleep diary results, N = 55	Premeasures, mean (SD)	Postmeasures, mean (SD)	Statistic	P-value	Wilks-lambda	Effect size (eta^2)
Sleep onset	Duration of going-to-bed-ritual Minutes per evening	21.25 (11.91)a	19.89 (12.33)a	T = 1.249	0.217	0.971	0.029
	Time of going to bed SD in minutes	20:31 (47.67)a	20:03 (48.66)a	T = −2.673	0.010	0.881	0.119
	Sleep onset latency Minutes	19.97 (15.55)a	18.26 (14.10)a	T = 1.022	0.311	0.981	0.019
	Use of external support to fall alseep(break/)Number of nights per week	4.89 (2.96)b	4.02 (3.22)b	Z = −2.375	0.018	0.901	0.099
Sleep maintenance	Frequency of night wakings Number per night	3.10 (2.08)a	2.27 (1.63)a	T = 3.418	0.001	0.819	0.181
	Duration of night wakings Minutes per night	47.86 (34.94)a	35.34 (34.53)a	T = 3.971	0.000	0.771	0.229
	If parents had to get up at night Number per night	1.98 (1.97)a	1.31 (1.22)a	T = 3.054	0.004	0.850	0.150
	Use of external support to maintain sleep(break/)Number of nights per week	6.04 (1.98)b	5.04 (2.96)b	Z = −2.824	0.005	0.857	0.143
	Co-sleeping Number of nights per week	4.87 (2.67)b	4.00 (2.98)b	Z = −3.394	0.001	0.798	0.202
	Nocturnal feeding Number of nights per week	4.63 (2.87)b	3.93 (3.09)b	Z = −2.411	0.016	0.884	0.116
General	Overall sleep duration Minutes per night	599.33 (52.04)a	616.37 (54.88)a	T = −3.222	0.002	0.836	0.164
	Sleep efficacy In percent	87.61 (6.26)a	90.42 (5.70)a	T = −4.084	0.000	0.761	0.239

Notes: Results were calculated via t-test or Wilcoxon test. Gaussian distribution was tested via Kolmogorov–Smirnov (K-S) test (α = 0.05);

a K-S test not significant;

b K-S test significant.

Abbreviation: SD, standard deviation.

Table 6 Results of the sleep behavior of the child: Child Behavior Checklist 1.5–5 (CBCL 1.5–5)

CBCL, N = 55	Premeasures, mean (SD)	Postmeasures, mean (SD)	Statistic	P-value	Wilks-lambda	Effect size (eta^2)
CBCL sleep-subscale
T-transformed value	65.35 (8.99)a	58.71 (11.67)a	T = 4.303	0.000	0.745	0.255
Sleeping alone	1.53 (0.69)b	1.09 (0.87)b	Z = −3.592	0.000	0.751	0.249
Difficulties falling asleep	1.38 (0.78)b	0.95 (0.87)b	Z = −3.403	0.001	0.791	0.209
Nightmares	0.35 (0.55)b	0.18 (0.43)b	Z = −3.000	0.003	0.836	0.164
Refusing to go to bed in the evening	0.71 (0.79)b	0.42 (0.57)b	Z = −2.696	0.007	0.871	0.129
Sleeping less than most other children at night	0.84 (0.88)b	0.55 (0.84)b	Z = −2.893	0.004	0.845	0.155
Talking, crying, screaming while sleeping	0.49 (0.74)b	0.55 (0.69)b	Z = −0.728	0.467	0.990	0.010
Night wakings	1.69 (0.66)b	1.24 (0.84)b	Z = −3.041	0.002	0.807	0.193

Notes: Item values: 0 = not applicable, 1 = a bit or sometimes applicable, 2 = exactly or often applicable. Results were calculated via t-test or Wilcoxon test. Gaussian distribution was tested via Kolmogorov–Smirnov (K-S) test (α = 0.05);

a K-S test not significant;

b K-S test significant.

Abbreviation: SD, standard deviation.

Table 7 Results of parental behavior changes in the sleep onset situation

Mini-KiSS Online Questionnaire (N = 55)	Premeasures mean (SD)	Postmeasures mean (SD)	Statistic	P-value	Wilks-lambda	Effect size (eta^2)
Child gets something to eat or to drink	2.65 (1.26)	2.79 (1.26)	Z = −1.889	0.059	0.934	0.066
Child is allowed to get up again	3.47 (0.79)	3.65 (0.62)	Z = −2.456	0.014	0.899	0.101
Somebody stays with the child until it fell asleep	1.60 (1.07)	2.00 (1.16)	Z = −3.068	0.002	0.831	0.169
Child is allowed to start sleeping in parents’ bed	2.69 (1.24)	2.95 (1.24)	Z = −1.772	0.076	0.945	0.055
Child is allowed to start sleeping next to the parents	2.87 (1.25)	3.05 (1.21)	Z = −1.731	0.083	0.943	0.057
Child is allowed to play or to watch TV	3.85 (0.41)	3.94 (0.23)	Z = −2.236	0.025	0.907	0.093
Child gets another bedtime-story or song	2.63 (1.22)	3.00 (1.16)	Z = −2.838	0.005	0.866	0.134
Parents scold the child	3.35 (0.78)	3.51 (0.79)	Z = −2.065	0.039	0.922	0.078
Child gets medicine	3.79 (0.66)	3.92 (0.43)	Z = −1.382	0.167	0.960	0.040

Note: Item values: 1 = usually/often applicable (5–7 times a week), 2 = sometimes (2–4 times a week), 3 = rarely (once a week), or 4 = not/never applicable. Results were calculated via Wilcoxon test because all variables failed Gaussian distribution (calculated via Kolmogorov–Smirnov test; α = 0.05).

Abbreviation: SD, standard deviation.

Table 8 Results of parental behavior changes in a night waking situation

Mini-KiSS Online Questionnaire (N = 55)	Premeasures mean (SD)	Postmeasures mean (SD)	Statistic	P-value	Wilks-lambda	Effect size (eta^2)
Child gets something to eat/drink	2.00 (1.26)b	2.35 (1.36)b	Z = −2.918	0.004	0.847	0.153
Somebody stays with the child until it fell asleep	1.67 (1.12)b	2.11 (1.21)a	T = −3.605	0.001	0.806	0.194
Child is allowed to stay the night in the parents’ bed	1.95 (1.16)b	2.31 (1.27)a	T = 3.112	0.003	0.845	0.155
Child gets bedtime-story or song	3.58 (0.90)b	3.76 (0.74)b	Z = −2.157	0.031	0.917	0.083
Parents scold the child	3.47 (0.74)b	3.65 (0.67)b	Z = −2.233	0.026	0.909	0.091
Parents take the child out of its bed and soothe it	2.28 (1.11)a	2.76 (1.08)a	T = −3.999	0.000	0.768	0.232
Parents soothe the child in its bed	1.98 (1.04)a	1.59 (0.92)b	T = 3.428	0.001	0.819	0.181
Parents lay down next to the child	2.94 (1.31)b	2.92 (1.28)b	Z = −0.183	0.855	1.000	0.000
Parents leave the child to cry for a while and see if child is able to self-soothe	2.84 (1.32)b	2.28 (1.29)a	T = 4.006	0.000	0.764	0.236

Notes: Item values: 1 = usually/often applicable (5–7 times a week), 2 = sometimes (2–4 times a week), 3 = rarely (once a week), or 4 = not/never applicable. Results were calculated via Wilcoxon test because all variables failed Gaussian distribution (calculated via Kolmogorov–Smirnov (K-S) test; α = 0.05).

a K-S test not significant;

b K-S test significant.

Abbreviation: SD, standard deviation.