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Sleep Grand Rounds Judith Owens MD MPH Director of Sleep Medicine

ABCs of Zzzzs : The Impact of Delaying High School Start Times on Adolescent Health, Safety and Performance. Sleep Grand Rounds Judith Owens MD MPH Director of Sleep Medicine Children’s National Medical Center Washington DC. Conflict of Interest Disclosures.

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Sleep Grand Rounds Judith Owens MD MPH Director of Sleep Medicine

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  1. ABCs of Zzzzs: The Impact of Delaying High School StartTimes on Adolescent Health, Safety and Performance Sleep Grand Rounds Judith Owens MD MPH Director of Sleep Medicine Children’s National Medical Center Washington DC

  2. Conflict of Interest Disclosures The material presented in this lecture has no relationship with any of these potential conflicts

  3. Objectives • To summarize the current literature regarding the impact of school start times • On the health risk behaviors, safety and performance of high school and middle school students • On implications for public policy at the individual school district, regional and national levels

  4. Adolescents: Later Bedtimes Circadian rhythm changes associated with pubertal stage (rather than chronological age) Shift (delay) to later sleep-wake times May be exacerbated by evening light exposure Accumulation of sleep drive changes Easier for adolescents to delay sleep onset; more difficult to initiate sleep Environmental factors Competing priorities for sleep: homework, activities, after-school employment, “screen time”, social networking

  5. Adolescents: Earlier Wake Times Earlier wake times Earlier school start times Often concurrent with adolescent phase delay, making it more difficult to fall asleep and to wake up Selective impact on REM%?

  6. Adolescents: Irregular Sleep/Wake Schedules Increasing discrepancy between WD/WE BT/WT Average 1.5-2 h delay BT; 3-4 h delay WT Adequate compensation for WD sleep loss? Compromised WD alertness Exacerbation circadian phase delay Shift melatonin onset Increased SOL Sunday night Weekly “jet lag” Associated EDS, poor academic performance, depressed mood Effects persist up to 3 days

  7. Adolescents: The Bottom Line Average sleep high school student needs:9 – 9.25hrs/night Average sleep high school student gets: 7.25hrs/night The Ideal: On a practical level, this means that the average adolescent has difficulty falling asleep before 11pm, and is best suited to wake around 8am The Reality: 80% of adolescents get < recommended 9 h sleep amount on school nights; 45% < 8h By 12th grade, average sleep on school nights is 6.9 h; 3%>9hrs 30-41% of 6th – 8th graders getting >9 hrs of sleep But, 71% of parents think their teens get enough sleep most nights NSF Poll data 2006

  8. * Sleep In Adolescents:A Public Health Crisis *Save Our Sleep

  9. Sleep and Cognitive Function • Experimental sleep restriction has selective effects on the prefrontal cortex (PFC) and “executive functions” • Flexibility • Planning • Problem-solving • Decision-making • Divergent thinking • Cognitive set shifting • Judgment, motivation • Monitoring, modifying and inhibiting behavior • Modulation of emotions • Most rapid development during adolescence

  10. Sleep impacts response to positive and negative stimuli: Increased response of the “emotional brain” (limbic system/striatum) Weaker PFC connectivity Heightened emotional response with less regulatory control Sleep and Emotional Regulation Guyar et al, 2007; Helm et al 2011

  11. Sleep and Risk Taking Behaviors • Selective areas of the brain (striatum) are important for reward-related function • Positive emotions • Motivation • Response to reward • These undergo structural/functional changes in adolescence • Studies suggest insufficient sleep linked to changes in reward-related decision making • Perceive less negative consequences, take greater risks O’Brien & Mindell 2005; Giedd 2009; Holm et al 2009

  12. A “Real World” Example • Large socioeconomically, racially and culturally-diverse school district in eastern US • 183,000 total students in 96 schools • 56,000 students in 26 HS • >1000 buses; 4 delivery tiers • Current start times: • HS 7:20am (bus pick-up starts 5:45am) • MS 7:45-55am • ES 8:05-9:10am

  13. Youth Risk and Protective Factors Survey • Administered annually to 8th, 10th and 12th graders in the school district • Surveys 2010, 2011, 2012 N=93,532 • Substance use, sexual activity, violence/delinquency, mood, health risk behaviors (physical activity, nutrition), assets (community involvement, peers) • Single sleep question: “On an average school night, how much sleep do you get?” (<4,5,6,7,8,9,10+) • Insufficient (<6hrs), Low Borderline (7hrs), High Borderline (8hrs), Optimal (9+)

  14. Sleep Duration* Note. Use 3-year overall sample of 90, 124 (96.4%) students in 8th, 10th, and 12th grade *unpublished data

  15. Mood Note. Use 3-year overall sample of 89,198 (95.4%) students in 8th, 10th, and 12th grade

  16. Alcohol Use Note. Use 3-year overall sample of 89,169 (95.3%) students in 8th, 10th, and 12th grade

  17. Binge Drinking Note. Use 3-year overall sample of 58,235 (96.2%) students in 10th and 12th grade

  18. Driving after Alcohol Use Note. Use 3-year overall sample of 58,368 (96.4%) students in 10th and 12th grade

  19. Prescription Drug Use Note. Use 3-year overall sample of 58,228 (96.2%) students in 10th and 12th grade *includes stimulants

  20. Youth Risk and Protective Factors Survey • The risk factor scales with the largest percentages of students considered to be at high risk were: • Insufficient Sleep (12th graders 55.8%) • Family Attitudes Favorable to Antisocial Behavior (45.0%) • Family Conflict (41.8%) • Insufficient Sleep (10th graders 41.5%) • Sensation Seeking (41.1%)

  21. Youth Risk and Protective Factors Survey • The protective factor scales with the largest percentages of students considered to have high protection were: • Social Skills (74.1%) • School Opportunities for Prosocial Involvement (69.3%) • Belief in Moral Order (66.9%) • Optimal Sleep • 10th graders (6.0%) • 12th graders (3.0%)

  22. Sleep and School Start Times

  23. School Start Times • Multiple studies show association decreased sleep duration with lower academic achievement • Studies comparing middle/high schools with earlier vs later start times show: • Shorter sleep duration • Erratic sleep patterns • Increased sleepiness • Dozing off in class • Difficulty concentrating • Increased rates tardiness • More stimulant use • MSLT results = level of daytime sleepiness seen in patient with narcolepsy (50%>1 SOREMP) 7:15 - 8:00a 7:15 – 8:37a 7:20 - 8:25a 7:40 - 8:25a 7:40 - 8:30a 8:00 - 8:30a

  24. Brief History of SSTC • Minnesota pioneers • 1996: Edina MN changed high school start times from 7:20am to 8:30am • 1997: Minneapolis changed high school start times from 7:15am to 8:40am; N>18,000 students • Since late 1990’s, ~1000 high schools in 70 districts report school start time delays; almost no schools have returned to the original bell times • 60% of 19,000+ public high school start after 8am

  25. Outcomes • Does delaying start time result in students obtaining more sleep, or do students just stay up later? • Minnesota: Average school night bedtime stayed constant at 10:40pm1 • In a study involving grades 6-12 in a school district that delayed high school start times by one hour (7:30 to 8:30am), bedtimes did not shift later2 • Independent school with delay start time of 30 minutes3 • School night BT advanced from 23:39 to 23:21pm 1Wahlstrom 2002; 2Danner and Phillips 2008; 3Owens 2010

  26. Outcomes • Does sleep duration increase/sleepiness levels decline? • Minnesota: Sleep duration increased by 1 hr/school night; 5 hrs/week1 • Public high school sophomores and juniors at later versus earlier starting high school reported more sleep and less daytime sleepiness2 • High school students slept an additional 35 minutes on average and experienced less daytime sleepiness after their school start time was delayed from 7:35 to 8:15 am3 • High school start times delayed from 7:30 to 8:30am, students averaged 12 to 30 minutes more nightly sleep; % of students who reported >8 hours of sleep increased from 37% to 50%4 • Independent school with 30 minute delay5 • Sleep duration increased from 7.11hrs to 7.86hrs • Percentage of students sleeping > 8 hrs/night in 8 public high schools (9000+ students) in 3 states6 • 33% at SST 7:30am • 66% at SST 8:55am 1Wahlstrom 2002; 2Dexter 2003; 3Htwe 2008; 4Danner and Phillips 2008; 5Owens et al 2010; 6Wahlstrom 2014

  27. Outcomes Percentage of students in each self-reported school night sleep duration category at Surveys 1 and 2 Owens et al 2010

  28. Outcomes • Independent school; students less likely to report (pre-post 30 min change):1 • Problem daytime sleepiness: 49% 20% (p<.001) • Sleepy in class: 85% 64% (p<.001) • Sleepy doing homework: 83% 63% (p=.001) • Fell asleep am class: 39% 18%(p<.001) • Arrived late: 36% 22% (p<.001) 1Owens et al 2010

  29. Outcomes • Independent NE Boarding School: start time delayed 25 minutes (8:00 to 8:25am)1 • No change average school night bedtimes • Sleep duration increased 30 minutes • Daytime sleepiness (napping, late to class, difficulty waking) significantly decreased • Decreased depression scores, caffeine consumption, health center fatigue visits • Students most likely to increase sleep • Baseline SD<8hrs (OR=5) • Students least likely to increase sleep • Being in 11th or 12th grades decreased odds of increasing sleep by 65% and 74% compared to 9th and 10th graders 1Boergers, Gable, Owens 2013

  30. Outcomes • Does school attendance improve? • Minnesota: 1 • Tardiness rates dropped • Daily attendance rates improved • Percentage of high school students continuously enrolled district/same school increased. • Drop-out rates declined • Chicago public high schools: absences much more common for first period classes compared to afternoon classes2 • Kentucky: 7:30 to 8:40a start time: Attendance up3 • Independent school: First class tardies/cuts: 36% decrease4 • Appropriation of federal dollars for schools partially dependent upon student attendance data; thus, reducing tardiness and absenteeism levels could result in increased funding and further offset costs related to moving start times later 1Wahlstrom 2002; 2Cortes et al 2010; 3Danner & Phillips 2008; 4Owens 2010

  31. Outcomes • Does academic performance improve? • Minnesota1 • Grades improved slightly (not statistically significant) • SAT scores for the top 10% of students jumped from 1288 to 1500 • Chicago public high schools2 • Student grades and test score performance notably lower for first period classes compared to afternoon classes • Performance on end-of-year subject-specific standardized tests (i.e., math, English) correlated with whether or not the student was scheduled for that subject during first period • Kentucky: 7:30 to 8:40a start time3 • Standardized test scores up • CDC study (2014)4 • 5/6 schools showed significant increase in GPA pre-post in English, math, science and social studies 1Wahlstrom 2002; 2Cortes 2010; 3Danner & Phillips 2008; 4Wahlstrom 2014

  32. Survey 1 Health center/MD visits for fatigue: 15.3% Rest request: n=69 First class tardies/cut: 158 Survey 2 Health center/MD visits for fatigue*: 4.6% (S1 vs S2 p=.03) Rest request: n=30 (56% decrease) First class tardies/cuts: 101 (36% decrease) Outcomes: Health and School Data Owens et al 2010

  33. Outcomes: Safety • Kentucky: 7:30 to 8:40a start time1 • Teens involved in car crashes down by 16% (vs 9% increase in the rest of the state) • Adolescent crash rates 40% higher in VA Beach (SST 7:20a) vs Chesapeake (SST 8:40a)2 • 2007: 71 vs 55/1000 (p<.001) • 2008: 66 vs 47/1000 • Peak 1 hour earlier • CDC (2014): Reduction crash rates in 16-18yo by 65-70%3 • Decreased sleep associated with increased sports-related injuries in high school athletes 1Danner & Phillips 2008; 2Vorona et al 2011; 3Wahlstrom 2014

  34. Outcomes: $$$ • Brookings Institute Report: “Organizing Schools to Improve Student Achievement: Start Times, Grade Configurations, and Teacher Assignments” (2011) • Moving school start times one hour later would have a substantial benefit: cost ratio (9:1) • Based on a conservative estimate of both costs per student ($0-$1950; largely related to transportation), and the increase in projected future earnings per student in present value due to test score gains (approximately $17,500) • “A later start time of 50 minutes in our sample has the equivalent benefit as raising teacher quality by roughly one standard deviation” West (2011) 3 AEJ: Econ. Policy

  35. Middle Schools • Data from the National Household Education Survey found the 2001 median middle school start time was 8:00am; more than 20% started at <7:45a • 75% of school offset times 5:45 to 6:45 AM (actigraphy) in 6th-8th graders; sleep period 500min 6th to 472 8th1 • Comparing school start 7:15a vs 8:37a2 • SD 51 min less • 18% vs 36% < 9hrs sleep • More daytime sleepiness, tardiness; lower grades Wolfson et al 2003; Wolfson et al 2007

  36. Middle Schools • Recent research shows that delaying school start times for middle school students is accompanied by positive outcomes similar to those found in high schools, including: • Later rise times • More school night total sleep • Less daytime sleepiness • Decreased tardiness rates • Improved academic performance • Better performance on computerized attention tasks Epstein 1998, Wolfson 2003, Spaulding 2005, Pagel 2007, Lufi 2011

  37. Is Federal Legislation the Answer? • Congresswoman Zoe Lofgren introduced bill H.R. 1267, "Zs to As Act" (1999, 2003) • Initially an “anti-crime, anti-teen pregnancy” bill • Bill would provide grants (up to $25,000) to local educational institutions that agree to begin school for secondary students after 9:00 am • National Petition: Promote legislation to prevent public schools from starting before 8 am • Sponsored by Start School Later: a national coalition working to ensure that all public schools can set hours compatible with health, safety, equity, and learning

  38. Pros and Cons • Requires all school districts to comply, reducing likelihood of scheduling conflicts among schools • Likely to result in faster implementation than “grass roots” approach • Raises awareness of adolescent sleep as critical health issue • School districts may view federal mandate as interfering with local community needs, circumstances, autonomy; risk of backlash • Does not provide support and education for implementation; likelihood of “buy-in” • Is 8am late enough?

  39. A Middle Ground? • Advocate for federal funding to: • Establish national tracking system for start times • Develop resources to provide support, education and consultation for school districts contemplating changes • Provide financial incentives for schools starting later • Fund research to determine barriers, assess outcomes (health/safety, academic achievement/graduation rates/college attendance, etc) across all types of school districts • Enlist professional organization endorsement (AASM/SBSM, APA, SAM, AAP, etc) • AAP Policy Statement (2014?) • Consider state-wide policies • MD legislature passes H.B. 883, "Study of Safe and Healthy School Hours for Maryland Public Schools," requiring Department of Health and Mental Hygiene to conduct a study of morning bell times (4/4/14)

  40. At the Local Level • CNMC contract 4/13 • Process • Individual stakeholder meetings (>45) • Large stakeholder meetings (3) • School Board presentations (2) • Town Hall public meetings (3) • Community presentations (10), webinars, local media interviews • Project website (smartschoolstart.org); posts Facebook, Twitter • Development of 17 transportation bell scenarios • Price tag range: $315K to $21 million • “Sweet spot” of biology/politics and logistics/cost • Deliverables • District “Needs Assessment” survey of principals report • 65% endorse HS current start time as “just right” • “Best Practices” review of national school districts • “Blueprint for Change” summary and recommendations

  41. SSTC: Lessons Learned • District superintendent support and leadership critical • School board involvement key • School leadership (ie, principals) and teacher support vital • Importance of middle/elementary school principal, teacher, parent involvement • Importance of student engagement • Critical role of community education • Health, safety and academics • Critical role of community engagement • Identification and involvement of key stakeholders

  42. SSTC: Lessons Learned • Transportation “drives” the process • Biggest source of logistical issues and cost • However, may result in cost savings (increased # tiers) • Critical to allow adequate time for families to become informed and make sufficient plans prior to implementation • Each community faces different, unique challenges • But you don’t have to “reinvent the wheel” • Not all students will benefit equally • The goal is to provide “the greatest good for the greatest number of students” • Anticipation often worse than reality (impact on athletics, teacher retention, after-school programs, childcare issues) • Initial challenges reduced over time

  43. Resources • http://smartschoolstart.org • http://schoolstarttime.org/ • http://www.startschoollater.net/ • http://www.endtherace.org/sleep-challenge

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