Adolescent Sleep Research: School Start Times

1. Adolescent Sleep Research:School Start Times Stacy Simera, MSSA, LISW-S, SAP

2. In 1998 the 5 public high schools in Fayette County, KY changed start times from 7:30 am to 8:30 am. In the two years afterwards:

3. In 1998 the 5 public high schools in Fayette County, KY changed start times from 7:30 am to 8:30 am. In the two years afterwards: • Auto accidents involving teens from Fayette Co. decreased 16.5%,

4. In 1998 the 5 public high schools in Fayette County, KY changed start times from 7:30 am to 8:30 am. In the two years afterwards: • Auto accidents involving teens from Fayette Co. decreased 16.5%, • while auto accidents involving teens in the state increased 7.8%...

5. In 1998 the 5 public high schools in Fayette County, KY changed start times from 7:30 am to 8:30 am. In the two years afterwards: • Auto accidents involving teens from Fayette Co. decreased 16.5%, • while auto accidents involving teens in the state increased 7.8%... • …a comparable decrease of 24.3%. (Danner and Phillips, 2008)

6. This is part of a slide show created by Stacy Simera, MSSA, LISW-S, SAP to educate professionals and communities on the research regarding adolescent sleep deprivation and early school start times. This can be shared as long as no references or citations are changed. You can contact Stacy in NE Ohio via this link: http://www.startschoollater.net/oh---northeast.html

7. The clinical research supporting later school start times for adolescents is abundant, however most of the data has been hidden away in scholarly journals. Even our future physicians have had little exposure to the research…

8. Sleep Education in Medical Schools - Curriculum Reviews - 1990 (Owens, 2005) Among medical schools that did offer sleep education, the average time spent was 2 hours.

9. The Minnesota Medical Association was one of the first groups to publicly address the issue. In 1993 the MMA issue a public resolution to educate the public on: • The need for more sleep during adolescence than during childhood • The biological shift to a later sleep pattern in adolescence • The impact of inadequate sleep on driving safety and school performance • The recommendation for schools to eliminate early starting times for adolescents (Minnesota Medical Association, mnmed.org)

10. Between the years of 1996 and 2003, grants were awarded to twenty medical schools for: • developing ‘model’ educational programs in the medical school • promoting ‘interdisciplinary learning environments’ • improving sleep education and research, including educating the public (Owens, 2005)

11. In 2000, the National Sleep Foundation published a 26-page report, Adolescent Sleep Needs and Patterns, that includes a discussion of the benefits of delaying school start times. Here is a link to that report: http://www.sleepfoundation.org/sites/default/files/sleep_and_teens_report1.pdf

12. Gradually other health professionals have become more aware of the research, in fact many groups have joined the MMA in forming policy statements on later school start times: • The Maryland State Medical Society • The American Lung Association of New England • The Connecticut Thoracic Society • The Virginia, Florida and Maryland chapter of the American Academy of Pediatrics • And more: http://www.startschoollater.net/position-statements.html

13. So what is the research saying?

14. Adolescent Sleep Needs • Adolescents require an average of 8.5 to 9.25 hours of sleep each night for optimum health

15. Adolescent Sleep Needs • Adolescents require an average of 8.5 to 9.25 hours of sleep each night for optimum health • In a study by O’Brien and Mindell (2005), only 9.2% of adolescents studied received 8 ½ hours of sleep or more during the week

16. Adolescent Sleep Needs • Adolescents require an average of 8.5 to 9.25 hours of sleep each night for optimum health • In a study by O’Brien and Mindell (2005), only 9.2% of adolescents studied received 8 ½ hours of sleep or more during the week • On average, most teens sleep 6.75 hours on school nights (Carskadon et al., 1980; National Sleep Foundation, 2009)

17. Circadian Rhythm • Our internal mechanism that controls the sleep/wake cycle (localized to the suprachiasmatic nucleus). • The circadian rhythm among humans averages 24.27 hours, but it ‘entrains’ to a 24-hour day based primarily on light exposure. (Crowley, Acebo and Carskadon, 2007)

18. Melatonin Melatonin is a hormone secreted by the pineal gland in response to the circadian rhythm: • Rising in the evening near the person’s usual bedtime • Remaining constant through sleep • Decreasing during the person’s usual wake time (Wahlstrom, 2003)

19. Melatonin Shift in Adolescence • Measuring of melatonin levels in saliva: - later onset of higher levels of melatonin among adolescents – as compared to younger children and older adults • Observed in other countries around the world: - a developmental condition of adolescence – not a cultural or scheduling phenomenon (Carskadon et al., 1979; National Sleep Foundation, 2009; Wahlstrom, 2003)

20. Thus adolescents naturally do not become sleepy until later in the evening, approximately 11pm, and are not alert until later in the morning - - therefore attempts at early bedtimes to compensate for early school times do not succeed.

21. Pubertal Maturation Correlation: Delay of circadian phase preference correlates with degree of pubertal maturation in a 1993 study by Carskadon et al: • Over 400 6th graders were scored according to their self-report of pubertal development • Those same students were then questioned on their preferences for daytime activity: morning or evening • Results showed that more mature students showed a preference for delayed phase compared to less developed students

22. Meta-Analysis of Phase Shift by Age(Crowley, Acebo and Carskadon, 2007)

23. Is Weekend Catch-Up OK? • No: Adolescents who sleep more on the weekend experience a ‘jet-lag’ effect, with negative effect on school performance. (Bergin and Bergin, 2009)

24. Why is sleep so important? • For our body: During stage 3 sleep we engage in tissue growth and repair and release of hormones. • For our brains: During stage 4 sleep our brain is active and is it suspected that we engage in reorganizing similar to ‘de-fragmenting’ in computers…

25. Non-REM Stage 1 Falling Asleep Light Sleep REM Every 90 min. Brain is Active, Dreams Each course gets longer through the night Non-REM Stage 2 Fully Asleep Body Temp Drops Non-REM Stage 3 Deep Sleep Restorative Tissue Repair/Growth Hormone Release

26. Impacts of Chronic Sleep Deprivation • Academic • Cognitive • Mood • Behavior • Health • Obesity • Safety

27. Academic Functioning • Poorer performance in morning classes • Poorer academic performance overall • Absenteeism • Tardiness (Bergin and Bergin, 2009; Carskadon et al, 1998; Kahn et al, 1989; Noland et al, 2009; Wahlstrom, 2003; Wolfson et al, 2007)

28. Grades related to sleep patterns (O’Brien and Mindell, 2005)

29. Grade Failure Students with more sleep deprivation are more likely to fail a grade compared to students with less sleep deprivation - - even when amount of homework completion is similar. (Kahn et al, 1989)

30. Cognitive Functioning • Decreased Attention • Deficits in Problem-Solving Abilities • Decreased Complex Decision Making (Gibson et al, 2006; Kilgore et al, 2007)

31. Mood and Behavior • Increased impulsivity • Increased irritability • Lower tolerance for frustration • Missing social and sports events (Bates et al, 2002; Gibson et al, 2006)

32. Mood and Cognitive Functioning: Sufficient vs. Insufficient Sleep(Gradisar et al, 2008)

33. Risk-Taking Behavior Adolescents with insufficient sleep (less 8.5 hours of sleep on week nights) engaged in more risk-taking behaviors (violence, unsafe behaviors, drug use, and sexual activities) than students who reported sufficient sleep. (O’Brien and Mindell, 2005) Kahn, et al (2006): “[Our] findings suggest that sleep deprivation significantly weakens the inhibition of aggression and willingness to behave in ways that facilitate effective social interaction, possibly through reduced metabolic activity in prefrontal regions of the brain important for personality, affect, and inhibitory behavior.”

34. Health • Decreased immune functioning • Decreased insulin secretion and decreased ability to utilize insulin • Association between MS and shift work before age 20 (after 9pm or before 7am) • More aggressive forms of breast cancer • Decreased collagen 1 production • More… (Buxton, 2012; Hedstrom et al, 2012; Lancer, 2009; National Sleep Foundation, 2009; Thompson et al, 2012, more…)

35. Obesity • Extensive research had been disproving the assumed link between TV and obesity. • Instead, researchers are finding a link between chronic insufficient sleep and obesity. • This link occurs along all ages, but the link is strongest among children. (Must and Parisi, 2009; Noland et al, 2009; Taheri et al, 2004)

36. Research by Taheri et al (2004):(Research on 1,024 people in a 15-yr sleep study) Findings: • Association between increased BMI and inadequate sleep (less than 8 hours per night) • Hormonal changes: • decreased leptin levels by 15.5% (a hormone that suppresses appetite) among people with inadequate sleep • increased ghrelin levels (a hormone that stimulates appetite) by 14.9%

37. Safety Driving while drowsy is a ‘major contributor’ to an estimated 100,000 motor vehicle crashes per year and results in more than 1,500 deaths nationwide (National Highway Traffic Safety Administration, 2005) “Adolescents are more likely than older drivers to be sleep-deprived because of school schedules, social activities, and shifting circadian rhythms.” (Danner and Phillips, 2008)

38. Sports Injuries 68% reduction in sports injuries among teens who slept at least 8 hours compared to teens who were chronically sleep deprived - ‘not acute lack of sleep before the big game’ (Milewski et al, 2012 – presented at AAP Oct 2012 Conference) Factors associated with injuries: chronic sleep deprivation, higher grade level Factors NOT associated with sports injuries: gender, weeks of participation in sports per year, hours of participation per week, number of sports the teen engaged in, strength training, private coaching, and subjective assessments of "having fun in sports” "Our study shows that everyone's mom was right when she said you need to get a good night's sleep. While this was felt to help you get good grades in school, we now see that it helps prevent sports injuries.“ - Dr. Matthew Milewski, Reuters interview, 10/23/12

39. Farm Families Agricultural work is more hazardous than non-agricultural occupations, with increased risk to young workers. (Chapman et al, 1998; Myers et al 2002) “Sleep deprivation is of particular concern among adolescents residing and working on farms” (Chapman, 2006)

40. So what do the experts say? School start times for 6th - 12th grades (and even into college) after 8:30 am or ideally after 9:00am. (Bergin and Bergin, 2009; Carskadon, et al 1998; National Sleep Foundation, 2009; Noland et al, 2009; Wahlstrom, 2003; Wolfson et al, 2007; and many more…)

41. Schools that have acted: Hundreds, if not now thousands, of schools have changed in response to the research. Here are two sites that provide a sampling: http://schoolstarttime.org/2011/06/12/schools-recently-delaying-start-times/ http://www.startschoollater.net/success-stories.html

42. And here’s just a few examples of the measured benefits:

43. In 1997… Minneapolis Public School District’s 7 high schools changed from: 7:15 am - 1:45 pm school days to 8:40 am - 3:20 pm school days (Affecting 18,000 students)

44. In a study 4 year after changes: “Contrary to the fears and expectations that a later start would result in students staying awake an hour later on school nights… Minneapolis high school students get five more hours of sleep per week than their peers [with early school start times].” (Wahlstrom, 2003)

45. Benefits of Later Start Times In Minneapolis (statistically measured): • Increased total sleep • Increased attendance • Reduced tardiness • Increased enrollment • Slight improvement in grades (“difficult to measure”) (Wahlstrom, 2003)

46. Benefits of Later Start Times Anecdotal and Survey Reports from Minneapolis: • According to the faculty and staff: • Less students falling asleep in class • Students more alert during first two periods • Improved student behavior • Quieter hallways • According to the students: • Learning was ‘easier’ (Wahlstrom, 2003)

47. Rhode Island Comparison: Late Starting (8:37 am) compared to Early Starting (7:25 am) Middle Schools: (Wolfson et al, 2007)

48. Rhode Island Comparison: Late Starting (8:37 am) benefits compared to Early Starting (7:25 am) Middle Schools: • Increased total sleep times • Less daytime sleepiness • Improved grades among females in 7th grade (no statistical difference among males) • Improved grades among both genders in 8th grade (Wolfson et al, 2007)

49. Wilton, Connecticut Changed start times in 2003 • A local sleep disorders center survey, one year later, showed that Wilton high-school students were obtaining an hour more sleep per night. “Six years later, no one is even looking back… Our students are happier, performing at the highest levels academically, and our sports teams continue to be the among the best in the state.” (CT LWV, 2009 Statement)

50. In 1998 the 5 public high schools in Fayette County, KY changed start times from 7:30 am to 8:30 am. In the two years afterwards: • Auto accidents involving teens from Fayette Co. decreased 16.5%, • while auto accidents involving teens in the state increased 7.8%... • …a comparable decrease of 24.3%. (Danner and Phillips, 2008)