Bert Mandelbaum, MD Princeton Nassau Pediatrics Montgomery and Hillsborough BOE School Physician

1. Adolescents, Sleep and School Start TimesCan we improve their lives by changing school start times? Bert Mandelbaum, MD Princeton Nassau Pediatrics Montgomery and Hillsborough BOE School Physician Chairman, Dept of Pediatrics, Penn Medicine Princeton Health Immediate President of the Medical Staff, Penn Medicine Princeton Health

2. Background • Abundance of evidence that lack of sleep has significant deleterious effects on adolescents • Impacts learning, mental health issues and safety • Major cause of lack of sleep is early school start times • Adolescents have shift in circadian rhythm by 2-3 hours secondary to melatonin release- • Melatonin release starts 10-11pm and goes through sunrise • Results in teens not being able to fall asleep easily before 10:30-11pm and cannot wake up naturally before sunrise • Recommendations from American Academy of Pediatrics, CDC, American Academy of Sleep Medicine and County Health Rankings strategies all agree: • school start times should not begin before 8:30am • Montgomery High School begins at 7:20am

4. What happens if you don’t sleep?(CDC website) • The American Academy of Sleep Medicine recommends that teenagers aged 13 to 18 years should regularly sleep 8 to 10 hours per day for good health • Adolescents who do not get enough sleep are more likely to: • Be overweight • Not engage in daily physical activity • Suffer from symptoms of depression • Engage in unhealthy risk behaviors such as drinking, smoking tobacco, and using illicit drugs • Perform poorly in school

5. Mental Health Overview in Children and Adolescents • 20% of youth ages 13 to 18 live with a mental health condition • 11% have a mood disorder • 10% have a behavior or conduct disorder • 8% have an anxiety disorder • Suicide is the second leading cause of death in youth ages 10-24

6. Who is Recommending Changing School Start Times?

7. Policy Statements- All recommend school start times starting after 8:30am for adolescents • American Academy of Pediatrics (AAP) 2014: “School Start Times for Adolescents” • American Academy of Sleep Medicine (AASM) 2017:“Delaying Middle School and High School Start Times Promotes Student Health and Performance” • CDC-https://www.cdc.gov/features/school-start-times/index.html • County Health Rankings and Roadmaps- http://www.countyhealthrankings.org/take-action-to-improve-health/what-works-for-health/policies/later-middle-and-high-school-start-times

8. Sleep- Policy makers agree • POLICY STATEMENTSchool Start Times for Adolescents – AAP 2014 • “In most districts, middle and high schools should aim for a starting time of no earlier than 8:30 AM. “ • “Insufficient sleep also takes a toll on academic performance” • “An increased prevalence of anxiety and mood disorders has also been linked to poor quality and insufficient sleep in adolescents.”

9. CDCAdolescents and sleep • “During puberty, adolescents become sleepy later at night and need to sleep later in the morning as a result in shifts in biological rhythms.1 • These biological changes are often combined with poor sleep habits (including irregular bedtimes and the presence of electronics in the bedroom).2 • During the school week, school start times are the main reason students wake up when they do.3 • The combination of late bedtimes and early school start times results in most adolescents not getting enough sleep.”

10. County Health Rankings and Roadmaps

11. County Health Rankings and Roadmaps • “Start times for middle and high schools are typically very early, often before 8 a.m., but can be delayed via policy change, often at the school or district level.” • “…delaying school start times substantially, until after 8:30 or 9:00 a.m., can provide an opportunity for students to get the recommended 8.5-9.5 hours of sleep on school nights”

12. Where’s the Evidence?

13. Does Delaying School Start Times just make them go to bed later? • Sleep Med Rev. 2016 Aug;28:86-95. doi: 10.1016/j.smrv.2015.06.002. Epub 2015 Jun 29. • Delayed school start times and adolescent sleep: A systematic review of the experimental evidence. (Minges KE1, Redeker NS2.) • School start times were delayed 25-60 min, and correspondingly, total sleep time increased from 25 to 77 min per weeknight.

14. Conclusion of the literature review: “Overall, the evidence supports recent non-experimental study findings and calls for policy that advocates for delayed school start time to improve sleep..”

15. Evidence for Changing School Start TimesScience Advances- Dec 12th, 2018

16. Sleepmore in Seattle (Dunster, Dec 2018) • “Most teenagers are chronically sleep deprived. One strategy proposed to lengthen adolescent sleep is to delay secondary school start times. This would allow students to wake up later without shifting their bedtime, which is biologically determined by the circadian clock, resulting in a net increase in sleep.” • “The Seattle School District delayed the secondary school start time by nearly an hour. We carried out a pre-/post-research study and show that there was an increase in the daily median sleep duration of 34 min, associated with a 4.5% increase in the median grades of the students and an improvement in attendance.”

17. Benefits found after 1 year • Longer sleep duration during the week • Less social jetlag (catch up sleep) on weekends • Better attendance • Less tardiness • Increased academic performance • Improved reported mood

18. Sleepmore in Seattle Discussion (Dunster, Dec 2018) • “We show that a delay in the high school start times from 7:50 to 8:45 a.m. had several measurable benefits for students. The change led to a significant lengthening of daily sleep of over half an hour” • “These results demonstrate that delaying high school start times brings students closer to reaching the recommended sleep amount and reverses the century-long trend in gradual sleep loss” • “We also show that the later school start time is associated with a better alignment of sleep timing with the circadian system (reduced social jet lag), reduced sleepiness, and increased academic performance “ • “

19. Sleepmore in Seattle Discussion (Dunster, Dec 2018) • “Last, the later school starts led to an increase in punctuality and attendance that, remarkably, was only evident in the economically disadvantaged school. Obviously, attending school and arriving on time to school is beneficial for learning, and this result suggests that delaying high school start times could decrease the learning gap between low and high socioeconomic groups.” • “Other studies have shown impacts of later school start times that are consistent with our findings”

20. Economic Case for Sleep- (Aaron Carroll, MD, New York Times, Sept 2017) • Referenced an economic analysis by Rand Corporation from 2017 • They found that the added academic benefit of later start times would be equivalent to about two additional months of schooling, which they calculated would add about $17,500 to a student’s earnings over the course of a lifetime.

21. Later school start times in the U.S.An economic analysis-2017- Rand Corporation • Even after just two years, the study projects an economic gain of $8.6 billion to the U.S. economy, which would already outweigh the costs per student from delaying school start times to 8:30 a.m. • After a decade, the study showed that delaying schools start times would contribute $83 billion to the U.S. economy, with this increasing to $140 billion after 15 years..

22. Where does the savings come from? • Decreased Car Crashes – tired teenagers • Better Education- higher HS graduation, better fund of knowledge

23. What Are Schools Doing Nationally? • Nationally (NCES, 2015): • o 82% of US middle schools start earlier than 8:30 • o 86% of US high schools start earlier than 8:30o 10% of high schools start earlier than 7:30 • **Montgomery High School- starts at 7:20am • **Montgomery Middle schools- start at 8:05am

24. What are the Obstacles Preventing Schools From Doing This?

25. Perceived obstacles to changing middle school/high school start times • Busing • After school activities/work • Sports- coordinating of games • Lighting for evening events • Parents schedule • Union/Teacher’s schedules • Younger students on earlier schedules- waiting for bus in the dark • Increased traffic around rush hour

26. Overcoming the Obstacles • All the obstacles are surmountable • Our primary goal should be the health and well being of the children • We can find ways to mitigate the secondary concerns that might arise from changing school start times, but that should not stop us from pursuing our primary goal

27. Common Worries that Never Materialized • “Here are some common worries that never materialized in the districts we studied: • The later start time may result in less participation in sports and fewer games won. • Because they get up later in the morning, teens may choose to stay up later at night. • Participation in after-school activities may decline. • Students might have difficulty arriving on time to after-school employment. • Transportation costs may increase. “ • Later start time for teens improves grades, mood, and safety Kyla L. Wahlstrom • August 14, 2017

28. Choosing NOT to Change The Start Times Has Significant Impacts

29. What are the negative impacts of NOT making the change? • Insufficient sleep in youth linked to... • Irritability / behavior problems (Baum et al., 2014; Sadeh et al., 2002; Stein et al., 2001) • Depression / Suicide Ideation (Liu, 2004; Roberts & Duong, 2014) • Compromised school achievement (Wahlstrom, 1999, 2002) • Missed school (Owens et al., 2010) • Poor health / illness (Eisenmann, 2006) • Obesity (Magee & Halle, 2012; Nielsen, Danielsen, Sorensen, 2011)

30. If Nothing Changes • Adolescents potentially getting home between 12 and 2; potentially with multiple unsupervised hours before any adult is around…leads to potential bad decision making- (vaping, alcohol, drugs, etc..) • Younger students- grades K-4 (ages 5-10) getting off a bus at 4:30, as it is getting dark. Leaving them little time to play outside and exercise

32. Potential Positive Outcomes

33. So What Are the Positive Impacts? • Later school start times linked to: • -Better grades, higher test scores, better attendance • -Teens that are “more easy to live with,” per parents • -Improved financial prospect (effects twice as large on disadvantaged students!) (Brookings Institute, 2011) • Later school start times also linked to: • -Less tardiness & drop-outs • -Less substance abuse • -Less depression • -Fewer car crashes (65-70%) (See Wahlstrom)

34. So What Are the Positive Impacts? • The eight hours of sleep seems to be a tipping point for making healthy or unhealthy behavioral decisions,” per lead author, K. Wahlstrom

35. Are there any potential solutions in Montgomery? • Transportation- Flip K-4 and HS to continue triple tier busing or propose new two tier busing solution • Sports- allow athletes to have a flex period at end of the day to leave school early for sports • Work with other School Systems for competitive sports- lead the change • Local sports and after school activities will follow suit to the school schedule

36. Conclusion

37. Conclusion • Teens need about 9.25 hours of sleep each night, a difficult amount to obtain when the brain doesn’t enter sleep mode until about 10:45 p.m. and when students must awaken early for a school day that begins before 8:30 a.m. Medical research has shown dramatic negative effects of sleep deprivation, especially in people who are chronically sleep-deprived. Depression, obesity, substance use and abuse, and increased car crashes are just some of the serious consequences. • Later start time for teens improves grades, mood, and safety Kyla L. Wahlstrom • August 14, 2017

38. Summary Recommendations • Go for the latest start time. • Research findings suggest that districts that make a modest move to a later start time for example, from 7:25 a.m. to 7:55 a.m. or from 7:35 a.m. to 8:05 a.m. experience modest benefits but also experience the same amount of community disruption as districts that make the change to start at 8:30 or later. In other words, the benefits are proportional to the amount of time change. Thus, when district leaders discuss whether to implement a later high school start time, they should select the maximum change possible. To make the change in stages or as a pilot will only lengthen the time, by years, that the community will have to deal with the disruption. • Later start time for teens improves grades, mood, and safety Kyla L. Wahlstrom • August 14, 2017

39. “Teens face an incredibly challenging world. Together, school leaders and parents have the responsibility to create the best possible conditions for them in which to grow and thrive. Implementing later high school start times is a significant change that positively affects their health, safety, and learning. If we have that will, we can find the way. “ • Later start time for teens improves grades, mood, and safety Kyla L. Wahlstrom • August 14, 2017

40. Conclusion • Evidence and national expert consensus policies support that early school start times are deleterious to adolescents health, well being and education • Changing school start times is an effective way to improve sleep and improve health, well being and education