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Supporting pupils to adopt good sleep hygiene using the HEAL principles: A case study

This case study is part of a bitesize CPD learning unit on sleep and screen time.

In the following video case study, Adele Normington, a wellbeing lead and mental health practitioner at a secondary school in Greater Manchester, discusses her approach to supporting pupils develop and maintain good sleep practices using the four HEAL principles from the Mental Health Foundation.

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Hello. And welcome to this presentation on sleep. My name is Adele Normington and I am a mental health practitioner and wellbeing lead at a secondary school in Greater Manchester. I previously worked with primary school children, secondary school children, all the way through to 18 years of age. And I work with pupils with mental health challenges and also support them with their being needs. 

And one of those needs is around sleep. So sleep challenges. So if we have a good night’s sleep, then we should wake up the next day feeling mentally and physically recharged and ready for the day ahead. 

But what happens if we don’t get enough sleep? Well, some of the short-term effects might be lack of concentration, memory problems, lack of attention, cognitive deficits, poor wellbeing, so people might become emotional or angry, anxiety might increase or even low mood. And then there are longer term issues such as a weakened immune system and also cardiovascular problems as well. 

So how do we get a good night’s sleep. So the Mental Health Foundation suggests that there are four pillars that underlie a good night’s sleep or a quality sleep. And the acronym for this is HEAL. So the H stands for Health, the E stands for environment, the A stands for attitudes, and the L stands for lifestyle. 

So health is if we have any physical health problems or even mental health problems then that can affect our quality of sleep. Even something just like having a cold can really affect how we sleep at night time. The environment that we sleep in is very, very important. So temperature, the comfort of the room, the noise levels of the room, and also the light in the room can all impact on the quality of sleep. 

So for example, if there’s too much light in the room it can be very difficult for us to get to sleep. And also attitudes. So an attitude such as ‘oh, I’m not going to be able to sleep tonight. I just know it’. Having that mindset can actually create a self-fulfilling prophecy. So if we have that mindset going to bed, then it’s more likely that we will have a poor night’s sleep. 

And then there’s also lifestyle. So lifestyle covers what we eat and drink, how we exercise, what time we go to bed, what time we wake up. So common factors that can affect our quality of sleep are caffeine, having exercise too close to bedtime, obviously going to bed too late at night, drinking alcohol. So then having a poor quality of sleep. So they are some of the factors that can affect a good night’s sleep. 

So I have been working with several pupils that have different sleep issues. And the one case study that I would like to talk about is a female pupil who is in upper school. And was referred to me on a one-to-one basis primarily because of anger issues. So she herself was becoming quite annoyed with the anger issues. 

So what I would do is I’d have a one-to-one consultation with her first which is private, and we go through a series of questions to try and identify what her needs are. And during that process, a couple of the questions that are asked are always around sleep and always around eating because those two basic needs, if we do not have those, then that can really have an impact on our mental health. 

So during the questioning around sleep, it became very apparent that this young person in her words couldn’t sleep. So she would be going to bed about 11 or 12 o’clock and then she would be on her mobile phone watching YouTube videos, on Snapchat, FaceTime, and friends till about 3AM, sometimes 4AM. 

So that then had a knock on effect on the time that she was getting up. So quite often, she would sleep through her alarm or she would turn her alarm off because she was too tired to get up. She described feeling very run down, having no energy, feeling quite fed up. And also because of this she was having time off school. 

So her absences increased and also her lateness. So because sometimes she would be in school late, she might miss period one, then she would get sanctions for a lateness. And then that would have an impact then on her mood and her anger levels and how she felt during the day. 

So together, we decided that it might be useful to have a look at sleep first and see if sleep was actually the underlying issue that was leading to the anger. And if we could improve our quality of sleep whether those anger issues would then subside. So during our first consultation session, that was agreed, then I scheduled another one-to-one session the week after. And during this session, we talked about goal setting so that she had a clear idea of what she was aiming for during our sessions together and what she wanted to achieve. 

And then we could measure the progress from week to week to see if any progress was being made. So the goals had to be hers. And she came up with a short-term goal of wanting to be able to attend school consistently on time for five days. That was her short-term goal. 

We then agreed to set a longer term goal. And her longer term goal was to increase her levels of motivation for school. She currently rated herself on a Likert scale of between 0 and 1. And she wanted to get up to about 7 out of 10 in motivation. And she said that we would see a change in her motivation levels because she would be volunteering to answer questions, she will be putting a hand up in class and participating much more. 

So our first intervention session is always about psychoeducation. So we discussed the purposes of sleep. I then outlined the four pillars underlying a quality night’s sleep, and asked her to write those down on a piece of paper. So she had a blank sheet of paper. She wrote the acronym across the top. And then she wrote the headings for each one underneath. 

And then what we did was we did a visual. So for health she drew some pictures of what her health was currently like, so colds, stayed in bed because she didn’t feel well. Then she drew some images of what the environment was like in her room. And the main issues were the mobile phone and the use of that in the early hours of the morning. She would fall asleep with it then she would wake up, and then she would set her phone to charge. 

So her phone was by her bed. And it was never switched on to silent. So if it pinged during the night, she could hear it. So we discussed that… is there any changes that she could be made. And reluctantly, she agreed there could be some changes. 

Then we looked at attitudes. And she filled out some speech bubbles on a piece of paper showing what her attitude was and that was ‘I can’t sleep without my mobile phone’, ‘it’s a waste of time’. 

And then we looked at her lifestyle. And she was very honest and she said that her lifestyle she didn’t really do anything because she was too tired. She was too tired she didn’t have the energy levels and just lost lots of motivation to do things. She was becoming really snappy with her friends and her family and was choosing more for alone time really in her bedroom. 

So that was session two, just outlining what the principles were and what that looked like for her. Towards the end of the session, we looked at what changes could be made. And again, I can make suggestions what the changes really need to come from her, because if we impose restrictions on young people, one, I’m not there to monitor it, and two, they can sometimes feel a little bit out of control. So everything that she did she chose to do. And it was small steps. 

So the first thing was she suggested that she could charge a mobile phone outside a room. She could still hear the alarm in the morning if it set off. So that was a small change to the environment. And we said, ‘right, let’s give that a go’. 

Also, obviously, going to bed a little bit earlier. So she set the time with maybe going to bed around about 10 o’clock, switching her phone off around about half past ten, and maybe listening to some gentle music to help her go to sleep. So there were some changes to the environment. 

The attitudes. She suggested that she could, again, maybe try something relaxing before bed. So maybe having a bath or something that would relax her so that she could feel more comfortable going to bed. And then the lifestyle change. She found would be a little bit more difficult initially just because she didn’t have as much energy as what she liked. So we decided that maybe those two changes would be enough to concentrate on over the next week, and then we could look at lifestyle a bit later on. 

I also advised her that change can take a while. It’s not something that just happens overnight, especially when we’ve had a series of maybe a sleep routine that isn’t that effective or what we would call poor sleep hygiene. So the main thing from that session was to set the goals for her to understand what the the four principles were from HEAL, to understand what her sleep routine was like and some changes that she could make to that and why she was doing it… what were the benefits of sleep? 

So I made another appointment. So she came back week 3. And there were some small differences. So in terms of her goal progress she had come into school more consistently. She hadn’t met the full week yet, but she’d come into school more consistently on time. She was starting to feel better. And she didn’t feel as reliant on her mobile phone. 

So then we talked about what other changes could be made, and introducing maybe some slight exercise into a daily routine. Just to walk a couple of times a week. She has a dog. So she agreed that she would walk the dog four or five times a week. 

And we also introduced the idea of a ‘worry diary’. So that before she went to bed, anything that she was worrying about or anything that was on her mind she could write down in a journal next to her bed and then that would go away in a drawer so that her mind was clear of any worries or anxieties and she didn’t need to check her phone. 

So by the time we had our fourth session, that’s when there were much more notable improvements. She described feeling more energetic. She said that she wasn’t as, in her words, as snappy with other people. She didn’t feel herself getting as angry and exploding as much. And her attendance had improved and also had been on time for lessons which then resulted in her getting rewards rather than sanctions and getting more praise from staff and from friends. So this then increased her self-esteem. 

And then she started to feel like, ‘I can do this. I can go to sleep. I can have a good sleep routine and actually maybe this is what is behind my anger’. 

So we continued session 5. And she felt that she’d made considerable progress towards her grades. During this time we recapped on the initial worksheets and made changes to her original routine and in highlighted what was working for her, and to keep going with this. 

So then we decided for her to put that into practice, and I scheduled an appointment with her at week 8, just to see what progress had been made and whether that was maintained. And the results there were clear to say. She was visibly brighter, much more… wanted to discuss lots of things, found she had completed her attendance. So she had been in every single day on time for at least a week, and it was actually more than that. 

And also I think one of the biggest changes that I noticed was she had signed up for a gym and she’d been looking at careers and hobbies and was signing up to be in the cadets. So that was something that she would never have imagined doing prior to this. So the progress was really, really good. 

So we agreed then that for her to keep up the routine. So again, the onus was on her then to continue that. She was in control. She knew what her positive bedtime routine was. She knew how to look after her health. 

She knew what the environment of her room. She knew what attitude she needed to have to go to sleep, and also how her lifestyle had changed, but then the knock-on effects of that. 

So she continued. And what we agreed then was that we would have a 12-month review or if she needed to see me before then she could come back. But so far then she’s not needed to. And it has been great progress. 

So the way that we discuss sleep across the school, because it is such an important factor, is that I will discuss sleep routines using the principles, from the Mental Health Foundation, of HEAL. I will do that one-to-one. I will do that in small groups. So sometimes when I have groups and we are discussing anxiety or low mood, we always come back to sleep and what the quality of sleep is like for that young person and whether any changes can be made. 

We also have posters around school outlining the acronym HEAL and what that is. I also have posters on the door of my office as well about the effects of quality sleep and what positive effects that can have on our physical and mental wellbeing. And then around exam time, I deliver whole-school assemblies, for mock exams and also for actual exams. And I do whole school assemblies throughout the year. And that is something that I also discuss during those assemblies. 

And then the… like I said, the posters, afterwards, are put around school so pupils can see those. And then there are also links to the Mental Health Foundation and the Sleep Foundation as well. 

Obviously, sleep is unique. It is individual. And for some people it may be more difficult even following those pillars of sleep. What I would advise is that if anybody is having ongoing issues with sleep, getting to sleep, staying asleep, waking up, not getting enough sleep, then to go and see the GP because there are a number of sleep disorders and it might just be that it needs investigating a little bit further.

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