Adolescent Sleep Research School Start Times Stacy Simera

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

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:

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%,

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%. . .

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)

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

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…

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.

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)

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)

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_report 1. pdf

• 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/positionstatements. html

So what is the research saying?

Adolescent Sleep Needs • Adolescents require an average of 8. 5 to 9. 25 hours of sleep each night for optimum health

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

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)

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)

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)

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)

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

Pubertal Maturation Correlation: Delay of circadian phase preference correlates with degree of pubertal maturation in a 1993 study by Carskadon et al: – Over 400 6 th graders were scored according to their selfreport 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

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

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)

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…

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

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

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)

Grades related to sleep patterns (O’Brien and Mindell, 2005) School Night Total Sleep Time Grades Low: ≤ 405 min High: ≥ 495 min As & Bs 52. 9% 62. 9% Bs & Cs 32. 9% 28. 6% Cs & Ds 12. 9% 8. 6% Ds & Fs 1. 2% 0% (≤ 6 ¾ hrs) (≥ 8 ¼ hrs)

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)

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

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

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

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. ”

Health • Decreased immune functioning • Decreased insulin secretion and decreased ability to utilize insulin • Association between MS and shift work before age 20 (after 9 pm or before 7 am) • 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…)

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)

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%

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)

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

Farm Families Agricultural work is more hazardous than nonagricultural 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)

So what do the experts say? th th School start times for 6 - 12 grades (and even into college) after 8: 30 am or ideally after 9: 00 am. (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…)

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-recentlydelaying-start-times/ http: //www. startschoollater. net/success-stories. html

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

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)

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)

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)

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)

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

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 7 th grade (no statistical difference among males) – Improved grades among both genders in 8 th grade (Wolfson et al, 2007)

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

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)

Even US Air Force Academy cadets (remember, puberty extends a few years beyond high school) benefited greatly from later class start times. A quote from the researchers is on the next slide, and a link to the study is here: http: //teensneedsleep. files. wordpress. com/201 1/05/carrell. pdf

“Our findings have important implications for education policy; administrators aiming to improve student achievement should consider the potential benefits of delaying school start time. A later start time of 50 minutes in our sample has the equivalent benefit as raising teacher quality by roughly one standard deviation. Hence, later start times may be a cost-effective way to improve student outcomes for adolescents. ” Carrell et al, A’s from Zzz’s, American Economic Journal: Economic Policy 3 August 2011): 62– 81, pg 80

The Brookings Institute’s Hamilton Project Policy Brief 2011 -08: ‘Organizing Schools to Improve Student Achievement’ is a report written by economists who estimate a ‘conservative’ 9 to 1 benefit to cost ratio in moving middle and high schools one hour later. That means communities get back $9 (or more) for every $1 spent on making the basic change. Most communities don’t have to spend anything, so the benefits can be limitless. Here is a link to that report: http: //www. hamiltonproject. org/files/downloads_and_links/092011_organiz e_jacob_rockoff_paper. pdf

Options for Schools 1) Delay all school start and end times 2) Exchange high school/middle school times with elementary school times – Elementary age students can adapt better to earlier bedtimes and waking times – No scientific reasons found in the literature on why districts tend to start high schools earlier than elementary schools 3) Compress high school and middle school days to delay the start time but retain current end time 4) Synchronize all school start and end times 5) Other? Come on – we can be creative for our kids!

Transportation Costs • Minneapolis, MN – No increase in cost – Shifted the same bus routes to later • Edina, MN – No increase in cost – Shifted the same bus routes to later • Hudson, OH – – Decreased cost Moved from 3 -tier to 2 -tier system Changed to an external vendor Consolidated routes, altered some pick-ups

Transportation Considerations • Transportation to Private Schools – In Hudson, a private school changed start time to coincide with Hudson schools • Transportation to Joint Vocational Schools – Many schools are looking at changing start times due to overwhelming research – ideally entire counties change times • Transportation to Alternative Schools – Seek cooperation, or even changes, from the alternative schools

And the million dollar question: What about sports?

Smart coaches remember that sleep deprivation increases sports injuries, reduces endurance, reduces speed, and reduces accuracy. But coaches also want to know what has happened to sports among schools that changed start times. So I contacted schools around the country and asked the people at the front lines and the sidelines, and these are some responses (shared with permission):

In Wilton, Connecticut ‘a self-described sports town’: After changes in school start times in 2003: • Participation in high school athletic programs ‘continued to rise’ • Upper elementary extracurricular involvement increased • Other schools in the conference accommodated late arrivals to events – with some of those schools ‘looking at making the change themselves’ (CT LWV, 2009 Statement)

St. George’s School, RI “We have found it (switching to 8: 30 start) one of the best things our school has ever done. The impact on athletics is minimal. Coaches have given up 5 minutes per day of practice time, willingly…” John R. Mackay Director of Athletics Head Football Coach (2/8/2011 email) St George’s School maintains 48 teams in 22 sports. Students are required to play at least 2 sports per season.

Fayette County, Kentucky “The time issue has never been a problem for us. Our schools start time is 8: 25 and practice after usually starts around 3: 30 or 3: 45. ” - Donald Adkins, Athletics Director Fayette County Schools, Kentucky 1/12/12 email

Lexington, Kentucky “The first question you asked was ‘do we have to get off the golf course before leagues? ’ We have a great relationship with our home course. They give us four tee times Monday to Thursday. Typically, any leagues start after our practices. …For bowling the additional time has not been an issue… In Lexington our leagues usually start around 6: 30 and we have been able to practice for two hours before then. ” - Bob Farquhar, Bowling and Golf Coach Lexington High School 5/15/12 email

Hudson, OH “It has actually worked out better than we anticipated. ” ~ “We have not really had any problems getting everything done before dark. ” -Ray Ebersole, Athletic Director Hudson Public High Schools 12/8/2011 and 5/13/2012 emails

Two Main Issues in Minneapolis, MN: 1) “Middle School students get out over an hour later than high school students. Basically, if a 7/8 th grade student participates on a high school team then they are forced to miss class on game days (the latter part of the day). Also, they miss practice because the times are staggered. If high schools and middle schools started/stopped at the same time we would not have this issue. ” 2) “We utilize our Minneapolis Public Parks for athletic fields. We are forced to be off most of them by 5: 45 pm. We don't start many of our games until 4 pm so this proves to be a big challenge. ” - Darren Ginther, Athletics Director Edison High School (12/8/11 email)

One solution in Minnesota: “Make connections. ” - Al Frost, Athletics Director Roosevelt High School, Minnesota (12/9/11 phone conversation) Mr. Frost made a deal with the park system, on whom the school relied for baseball and softball fields, to push the adult softball leagues a little later in exchange for the use of the school’s football field by the park system’s pee-wee football league.

Counterproductive Responses Changes that defeat the purpose of early start-times or minimize the focus of education within the educational system: – Shifting athletic practices or club meetings to before school – Extending extra-curricular activities past 9 pm (not recommended by researchers) – Having students leave during the last period(s) of school to get to athletic or club events

Childcare – Schools need to give adequate notice – Collaborate with daycares and extracurricular programs – Develop tutoring programs after school for younger children if elementary is moved earlier – Think outside the box: allow young students to ride the bus home with older siblings if schools choose to ‘flipflop’ high school with elementary

Short-Term Recommendations – Give standardized testing after 10 am, when adolescents are more alert – Decrease nightly homework hours – Give plenty of notice for large assignments – Educate schools, physicians, mental health providers on the impact of sleep deprivation – Educate parents that weekend ‘catch-up’ is normal, however sleeping beyond 2 -3 hours past normal wake time is not recommended (Hansen, et al 2005; Wolfson and Carskadon, 2005)

Get Involved! • Ask your school to look at the research. • Ask groups in your area to write letters of endorsement. • Start or sign local petitions. Go to www. signon. org to see if a petition already exists for your area – such as Northeast Ohio or Seattle. • Check out the national group Start School Later on Face. Book or at their website, where you can find a national petition: www. startschoollater. net

For more information: www. schoolstarttime. org www. startschoollater. net www. sleepfoundation. org

References • • Bates, J. , Viken, R. , Alexander, D. , Beyers, J. , & Stockton, L. (2002). Sleep and adjustment in preschool children: Sleep diary reports by mothers related to behavior reports by teachers. Child Development, 73(1), 62 -74. Bergin, C. , & Bergin, D. (2009). Sleep: The E-Z Z Z Intervention. Educational Leadership, 67(4), 44 -47. Retrieved from Academic Search Complete database. Carskadon, Mary. 2002. Frontline Interview. Available at: http: //www. pbs. org/wgbh/pages/frontline/shows/teenbrain/interviews/carskadon. html Chapman, LJ. Summary of NIOSH-Funded Research in Agriculture at University of Wisconsin. 2006. http: //www. cdc. gov/niosh/nas/agforfish/pdfs/app 2 -11. pdf Chapman LJ, Taveira AD, Newenhouse AC, Meyer RH, Josefsson KG. Causal factors in production agriculture injuries: working children and youth versus adults. In S. Kumar (Ed. ) Advances in Occupational Ergonomics and Safety. Washington DC: IOS Press 1998: 73 -76. Crowley, S. , Acebo, C. , and Carskadon, M. A. Sleep, circadian rhythms, and delayed phase in adolescence. Seep Medicine, Sep 2007, Vol 8, Issue 6, p 602 -612. Danner F, Phillips B. Adolescent sleep, school start times, and teen motor vehicle crashes. J Clin Sleep Med 2008; 4: 533— 5 Gibson, E. , Powles, A. , Thabane, L. , O'Brien, S. , Molnar, D. , Trajanovic, N. , et al. (2006). "Sleepiness" is serious in adolescence: Two surveys of 3235 Canadian students. BMC Public Health, 6116 -9. doi: 10. 1186/1471 -2458 -6 -116.

• • Gradisar, M. , Terrill, G. , Johnston, A. , & Douglas, P. (2008). Adolescent sleep and working memory performance. Sleep & Biological Rhythms, 6(3), 146 -154. doi: 10. 1111/j. 14798425. 2008. 00353. x. Hansen, M. , Janssen, I. , Schiff, A. , Zee, P. , & Dubocovich, M. (2005). The Impact of School Daily Schedule on Adolescent Sleep. Pediatrics, 115(6), 1555 -1561. doi: 10. 1542/peds. 20041649. Kahn, A. , Van de Merckt, C, Rebauffat, E. , Mozin, M. , Sottiaux, M. , Blum, D. , et al. (1989). Sleep problems in healthy pre-adolescents. Pediatrics, 84(3), 542 -546. Kahn-Greene, E. , Lipizzi, E. , Conrad, A. , Kamimori, G. , & Killgore, W. (2006). Sleep deprivation adversely affects interpersonal responses to frustration. Personality & Individual Differences, 41(8), 1433 -1443. doi: 10. 1016/j. paid. 2006. 002. Killgore, W. , Kahn-Greene, E. , Lipizzi, E. , Newman, R. , Kamimori, G. , & Balkin, T. (2008). Sleep deprivation reduces perceived emotional intelligence and constructive thinking skills. Sleep Medicine, 9(5), 517 -526. doi: 10. 1016/j. sleep. 2007. 003. Kubow, P. , Wahlstrom, K. , & Bemis, A. (1999). Starting Time and School Life. (Cover story). Phi Delta Kappan, 80(5), 366. Retrieved from Academic Search Complete database. Meyers, J, Miles, J, Faucett, J, Janowitz, I, Tejeda, D, Weber, E, Smith, R, Garcia, L. (2002) Priority risk factors for back injury in agricultural field work: Vineyard ergonomics. Journal of Agromedicine, (1), 37 -52. Must, A. , & Parisi, S. (2009). Sedentary behavior and sleep: paradoxical effects in association with childhood obesity. International Journal of Obesity, 33 S 82 -S 86. doi: 10. 1038/ijo. 2009. 23

• • • National Highway Traffic Safety Administration. Drowsy driving. Ann Emerg Med 2005; 45: 433 --4. National Sleep Foundation. 2009. Washington, DC. www. sleepfoundation. org Noland, H. , Price, J. , Dake, J. , & Telljohann, S. (2009). Adolescents’ Sleep Behaviors and Perceptions of Sleep. Journal of School Health, 79(5), 224 -230. O'Brien, E. , & Mindell, J. (2005). Sleep and Risk-Taking Behavior in Adolescents. Behavioral Sleep Medicine, 3(3), 113 -133. doi: 10. 1207/s 15402010 bsm 0303_1. Owens, J. (2005, January). Introduction to special section: NIH Sleep Academic Award program. Sleep Medicine, pp. 45 -46. doi: 10. 1016/j. sleep. 2004. 11. 001. Taheri, S. , Ling, L. , Austin, D. , Young, T. , & Mignot, E. (2004). Short Sleep Duration Is Associated with Reduced Leptin, Elevated Ghrelin, and Increased Body Mass Index. PLo. S Medicine, 1(3), 210 -217. doi: 10. 1371/journal. pmed. 0010062. Wahlstrom, K. (2003). Later High-School Start Times Still Working. Education Digest, 68(6), 49. Retrieved from Academic Search Complete database. Wolfson, A. , & Carskadon, M. (1998). Sleep schedules and daytime functioning in adolescents. Child Development, 69(4), 875. Retrieved from Academic Search Complete. Wolfson, A. , & Carskadon, M. (2005). Meeting Teen Sleep Needs Creatively. Education Digest, 71(1), 47 -51. Retrieved from Academic Search Complete database. Wolfson, A. , Spaulding, N. , Dandrow, C. , & Baroni, E. (2007). Middle School Start Times: The Importance of a Good Night's Sleep for Young Adolescents. Behavioral Sleep Medicine, 5(3), 194 -209. doi: 10. 1080/15402000701263809.