School Start Times: Implications and Solutions Stacy Simera, MSSA, LISW-S, SAP ssimera@aol.com

The Crux of the Issue Various health groups have recommended later middle and high school start times. Why the focus on those age groups?

Research reveals that puberty creates a temporary change in circadian rhythm: Adolescent melatonin secretion stops 09:00 22:30 Adolescent melatonin secretion starts

In addition to later secretion of melatonin, adolescents also experience an extended sleep drive. These pubertal changes occur in adolescents around the world and are physiological, not social or habitual. Teens obtain their healthiest sleep from approximately 11 p.m. to approximately 8 or 9 a.m. Early wake times directly disrupt and reduce teen sleep.

Impacts of chronic sleep loss: A brief literature review…

Sleep and Mental Health Johnson, Chilcoat, and Breslau, 2000: Increased risk of future depression and anxiety among children with deficient sleep

“Unlike other suicide risk factors, sleep complaints Sleep and Suicide Over 60 studies have found correlations between chronic insufficient sleep and suicide. “Unlike other suicide risk factors, sleep complaints may be particularly amenable to treatment.” (pg 1) Bernert and Joiner, Sleep disturbances and suicide risk: A review of the literature. 2007.

Sleep and Multiple Sclerosis Hedström et al, 2011: 1343 incident cases of MS vs. 2900 controls 5129 prevalent cases of MS vs. 4509 controls Working night shift before age 20 doubled the risk of multiple sclerosis

Sleep and Sports Injuries Dr. Matthew Milewski, 2012, AAP Annual Conference Published 2014 68% fewer sports injuries among teens with more than 8 hrs of sleep compared to their peers with less

Auto Accidents: Minnesota In 2005 the Mahtomedi School District moved start times from 7:30 am to 8:00 am. During that school year, auto accidents among 16-18year olds in the district decreased by 65% (Wahlstrom et al, 2014 – UMN CAREI Studies)

Auto Accidents: Wyoming In 2012 the Jackson Hole School District moved start times from 7:35 am to 8:55 am. During that school year, auto accidents among 16-18year olds in the district decreased by 70% (Wahlstrom et al, 2014 – UMN CAREI Studies)

Sleep and Illnesses (N=56 teens) Two main findings: Acute illnesses were more frequent in otherwise healthy adolescents with shorter sleep Illness events were associated with less sleep during the previous week than comparable matched periods without illness (Orzech et al, 2013)

Sleep and Dietary Choices 13,284 teens surveyed. Teens who slept less than 7 hours per night (compared to teens who slept more) were: More likely to consume fast food two or more times per week Less likely to consume fruits and vegetables Despite race, gender, SES, physical activity and family structure “…we need to start thinking about how to more actively incorporate sleep hygiene education into obesity prevention and health promotion interventions.” -Lead researcher Dr. Lauren Hale, Stony Brook Medicine Press Release, June 20, 2013

Sleep and Insulin Resistance Matthews et al, 2012: 245 healthy white and black adolescents: Elevated insulin resistance [HOMA-IR] associated with shorter sleep duration Findings were independent of age, race, gender and adiposity [amount of body fat] “…interventions designed to extend sleep in short sleepers may be beneficial for metabolic health in adolescence and beyond.” (pg 1357)

Sleep and Risk-Taking Behavior O’Brien and Mindell, 2005: Adolescents with less than 8.5 hrs sleep per night engaged in more violence unsafe behaviors drug use sexual activities Kahn et al, 2006 – similar results: “[Our] findings suggest that sleep deprivation significantly weakens the inhibition of aggression… through reduced metabolic activity in prefrontal regions of the brain….” (pg 214)

Sleep and Weapons (Analysis of 2009 YRBS data, N=14,782) High school boys with less than 8 hrs sleep on school nights were more likely to carry a weapon on school property (Hildenbrand et al, 2013) “Our findings suggest that sleep education interventions may serve as a viable avenue for enhancing school violence prevention efforts.” (pg 413)

Sleep and School Victimization (Analysis of 2009 YRBS data, N=14,782) High school students with less than 8 hours of sleep were more likely to: Miss school because they felt unsafe at school or on their way to or from school Have been threatened or injured with a weapon on school property Be bullied on school property (Hildenbrand et al, 2013)

Sleep and Pedestrian Safety Study by Davis et al (2013) of 14 and 15 yr olds: 50% increase in ‘hits’ or ‘close calls’ in virtual reality cross-walks when sleep-restricted (4hrs) Researchers’ Recommendations: 1. Explore policies regarding school start times 2. Better sleep hygiene education 3. Better parent education

(Wahlstrom et al, 2014 – UMN CAREI Studies) Sleep and GPA Increase in GPA in core courses in 5 of 6 high schools studied after changing start times: School Start Time Change Mahtomedi, MN 7:30am → 8:00am South Washington, MN 7:35am → 8:35am Boulder, CO 7:30am → 8:00 am (9am on Wed) Fairview, CO 7:35am → 8:05am Jackson Hole, WY 7:35am → 8:55am St. Louis, MN * (*results not statistically significant) 7:50am → to 8:20am (Wahlstrom et al, 2014 – UMN CAREI Studies)

(Lead author Scott Carrell: UC Davis Department of Economics) Sleep and Grades Study of 6,165 US Air Force Academy cadets over 4 years. (Carrell et al, 2011) Cadets with 7:50 am classes courses performed better in all their courses for that day compared to cadets with 7:00 am classes 50 minute later start improved teacher quality by one standard deviation “…later start times may be a cost-effective way to improve student outcomes for adolescents” (pg 80) (Lead author Scott Carrell: UC Davis Department of Economics)

Sleep and Disparities: ‘Insufficient Sleep and the Socioeconomic Status Achievement Gap’ – Buckhalt, 2011: “Insufficient sleep in children from low SES negatively affects them to greater degree than it does more advantaged children… …This view is consistent with the idea that when multiple health disparities associated with low SES are present, any single additional stressor has a greater effect.” (pg 63)

Sleep and Disparities: Hamilton Project Report: ‘Organizing Schools to Improve Student Achievement’ – Jacob and Rockoff, 2011: “The earliest school start times are associated with annual reductions in student performance… equivalent to replacing an average teacher with a teacher at the sixteenth percentile in terms of effectiveness.”

Sleep and Emotional Intelligence (Kilgore et al 2008, study of baseline and post-sleep deprivation testing) Total sleep deprivation resulted in: Lower emotional intelligence Poorer constructive thinking Poorer stress management Reduced empathy More reliance on superstition and ‘magical thinking’

Emotional Intelligence Risk-Taking Obesity Stress Grades Sports Injuries Car Crashes Cancer Suicide Depression Drug Use Disparities High Blood Pressure Diabetes Pedestrian Accidents Emotional Intelligence Violence Anxiety Food Choices Immune Functioning Stroke

Research database available via www.StartSchoolLater.net

Adolescent Sleep Needs 8.5 – 9.5 hours (more for athletes) Less than 10% of high schoolers get 9 or more hours of sleep per night The average adolescent sleeps 6.75 hrs on school nights 14 13 12 11 10 9 8 7 6 (Source: 2007 – 2013 YRBS)

Percentage of high school students who obtain 9 or more hours of sleep on school nights: (Source: 2007 – 2013 YRBS)

Students who obtain more than 8 hours of sleep on an average school night – by grade. (Note: adolescents require around 9 hrs of sleep.) (Source: 2015 YRBS) 9th grade 34.4% 10th grade 28.4% 11th grade 22.9% 12th grade 22.4%

Adolescents are the most sleep-deprived age group in the United States

Primary Culprits in Teen Sleep Loss #1: Early Wake Times #2: Evening Stimulation #3: Lack of Awareness

#1: Early Wake Times The Problem: Early wake times are the primary culprit in teen loss due to the later shift in sleep cycle during puberty. Waking at teen at 5am disrupts the sleep cycle and is biochemically similar to waking an adult at 2am. The Solution: Follow CDC and other health group recommendations and start middle and high schools after 8:30am.

The first health group to speak on the issue was the Minnesota Medical Association in 1993, when they passed a resolution to educate the public on: 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)

In 2000 the National Sleep Foundation released a publication on adolescent sleep that highlighted the benefits of later school start times

In 2011 the National Education Association passed a resolution supporting ‘school schedules the follow research-based recommendations regarding the sleep patterns of age groups’

In September of 2011 the Brookings Institution released a Hamilton Project policy brief, written by economists, recommending later middle and high school start times due to the economic benefits

In the spring of 2014 the Education Commission of the States released this policy brief recommending later school start times for adolescents. The ECS is a non-partisan think-tank created by the states. They conclude: “Few, if any, educational interventions are so strongly supported by research evidence from so many different disciplines and experts in the field.” (pg 3)

In August of 2014 the American Academy of Pediatrics released their landmark position statement calling for middle and high schools after 8:30am

In March of 2015 the National Association of School Nurses and the Society of Pediatric Nurses released a joint consensus statement supporting the AAP recommendations of school start times after 8:30am for adolescents

In June of 2015 the American Thoracic Society released a statement citing health concerns of insufficient sleep and recommending schools align their schedules with adolescent circadian propensity.

In August of 2015 the Centers for Disease Control released statistics on school start times and recommended middle and high schools start after 8:30am

In June of 2016 the American Medical Association adopted a position endorsing school start times no earlier than 8:30 a.m. for middle and high schools.

“Individual teens and families can set healthier bedtimes “Individual teens and families can set healthier bedtimes. But if you want to change hundreds or thousands of lives quickly, consider alleviating the pressure from early school start times.” - Dr. Dean Beebe P.hD., ABPP Professor of Pediatrics Cincinnati Children’s Hospital Medical Center University of Cincinnati College of Medicine

More position statements can be found at Start School Later’s website: www.startschoollater.net/position-statements

#2: Evening Stimulation The Problem: Adolescents are naturally wired to become sleepy around 10 or 11pm. Evening stimulation such as blue light exposure from mobile devices, caffeine within 6 hours of bedtime, nicotine, and late exercise can delay sleep onset even later. The Solutions: Educate parents and students on healthy sleep hygiene. Limit late night sports practices and events.

#3: Lack of Awareness The Problem: Most professionals and the public are not aware of the immediate and long-term implications of sleep loss. Many people are aware teens don’t get enough sleep, but they assume the only impact is temporary fatigue. The Solution: Share the research on the impacts of chronic sleep loss on health, mental health, safety, and learning

“Ignorance is the worst sleep disorder of them all.” - Dr. William Dement Stanford University The Promise of Sleep

In August of 2013 physicians with the Centers for Disease Control called for better awareness of sleep as a public health issue: https://www.cdc.gov/pcd/issues/2013/13_0081.htm

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 years later: “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) 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)

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)

What about sports?

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 Note: When this school district changed start times, teen auto accidents decreased 24.3% (Danner& Phillips, 2008) “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

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

Short-Term Recommendations Give standardized testing after 10am, 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 hours past normal wake time is not recommended (Hansen, et al 2005; Wolfson and Carskadon, 2005)

Resources for Schools University of Minnesota: “Implementing Later Start Times:” https://umconnect.umn.edu/p66919141/ Children’s National Medical Center – Blueprint for Change Team: “School Start Time Change:” www.tinyurl.com/FCPSBlueprint4Change Student education - posters and curriculum - extensive list compiled on Ohio Adolescent Health Partnership website: http://www.ohioadolescenthealth.org/sleep-resources.html More resources: www.startschoollater.net

Reference Sampling – also follow live links on slides when available: Chorney, DB, Detweiler, MF, Morris, TL & Kuhn BR. (2008) The Interplay of Sleep Disturbance, Anxiety and Depression in Children. J. Pediatr. Psychol. 33 (4): 339-348. Crowley, S., Acebo, C., and Carskadon, M.A. Sleep, circadian rhythms, and delayed phase in adolescence. Sleep Medicine, Sep 2007, Vol 8, Issue 6, p602-612. Davis L, Avis K, Schwebel DC. (2013) The Effects of Acute Sleep Restriction on Adolescents’ Pedestrian Safety in a Virtual Environment. Society for Adolescent Health and Medicine Vol 53, Issue 6, pp 785-790. 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. Milewski, MD, Pace, JL, Ibrahim, DA, Greg Bishop, G, Barzdukas, A. and. Skaggs, DL. (2014) Chronic lack of sleep is associated with increased sports injuries in adolescent athletes. J Pediatr Orthop March; 34(2): 129-33. Must, A., & Parisi, S. (2009). Sedentary behavior and sleep: paradoxical effects in association with childhood obesity. International Journal of Obesity, 33S82-S86. doi:10.1038/ijo.2009.23  Noland, H., Price, J., Dake, J., & Telljohann, S. (2009). Adolescents’ Sleep Behaviors and Perceptions of Sleep. Journal of School Health, 79(5), 224-230. doi:10.1111/j.1746-1561.2009.00402.x OBrien, E., & Mindell, J. (2005). Sleep and Risk-Taking Behavior in Adolescents. Behavioral Sleep Medicine, 3(3), 113-133. doi:10.1207/s15402010bsm0303_1. Rosen RC, Rosenkind M, Rosevar C, Cole WE, Dement WC. Physician education in sleep and sleep disorders: a national survey of U.S. medical schools. Sleep. 1993;16(3):249-254. Rosen R, Mahowald M, Chesson A, et al. The Taskforce 2000 survey on medical education in sleep and sleep disorders. Sleep. 1998;21(3):235-254. 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. PLoS Medicine, 1(3), 210-217. Teodorescu MC, Avidan AY, Teodorescu M, et al. Sleep medicine content of major medical textbooks continues to be underrepresented. Sleep Med. 2007;8(3):271-276. Wahlstrom, Kyla; Dretzke, Beverly; Gordon, Molly; Peterson, Kristin; Edwards, Katherine; Gdula, Julie. (2014). Examining the Impact of Later High School Start Times on the Health and Academic Performance of High School Students: A Multi-Site Study.