Adolescent Health and Later School Start Times Ashland School Start Times Committee Isha Ann Emhoff, MD FACS

Later School Start Times “Given that the primary focus of education is to maximize human potential, then a new task before us is to ensure that the conditions in which learning takes place addresses the very biology of our learners.” Mary Carskadon, PhD Brown University

Circadian Rhythm Circa Diem: around the day Biologic endogenous time: “built in clock” o Genetic o Brain hypothalamus Suprachiasmatic Nucleus (SCN) What is the purpose? o Allows anticipation and preparation for precise and regular environmental changes o Regulates metabolic processes o Brain wave activity o Temperature regulation o Hormone production (cortisol)

Melatonin Secretion Changes Child to Adolescent

Rhythmic Sleepy Time Source: Adapted from data given by National Sleep Foundation

Why Does Melatonin Rhythm Matter? Waking a teenager at 7:00 am is like waking an adult at 4:00 am

Pubertal Time Bending Sleep-Wake Phase Delay o 2 hour delay relative to mid-childhood o Fall asleep later and wake up later Delayed nocturnal melatonin secretion o Shift in circadian phase preference o Cannot just go to bed earlier – they cannot fall asleep o High level of alertness at 8 PM, even higher at 10 PM Altered sleep drive o Pressure to fall asleep accumulates more slowly o Takes longer to fall asleep o Difficulty falling asleep until after 11:00 PM

Sleep Time Delay Students lose up to 120 minutes of sleep per school night 1 Weekend Catch-up Sleep o Moves their inner clock even further away from the external clock o Worsens morning sleepiness at school Keep the weekday schedule on weekends No napping Equivalent to 5 hours jet lag on Monday morning 1. Martha Hansen, et al. The Impact of School Daily Schedule on Adolescent Sleep Pediatrics 2005; 115:

Optimal Timing hours per night 11:00 PM bedtime 8:00 AM wake time

Where do the Hours Go? Late school start time schedule o Alarm sounds at 7:30am o Bus stop 8:20am o School 9:00am to 3:50pm o Stay at school o Load buses for travel to away game at 4:30pm o Game 7:00pm to 9:00pm o Home between 9:45 pm to 10:30pm o Homework 10:30pm to 12:30am o Bed 12:30 am or 1:00am Sleep 6.5 to 7 hours Early school start time schedule o Alarm sounds 5:30am o Bus stop 6:20am o School 7:00am to 1:50pm o Return home on bus 2:15pm o Back to school to travel to away game 4:30pm o Game 7:00pm to 9:00pm o Home between 9:45pm to 10:30pm o Homework 10:30pm to 12:30am o Bed 12:30 or 1:00am Sleep 4.5 to 5 hours

Cognitive deficits Impaired executive function Deficits in abstract thinking and verbal skills/creativity Decreased performance efficiency and output Lower academic achievement Poor school attendance Increased dropout rates Drowsy driving Increased sports injuries Increased Anxiety, Depression, Suicidal Ideation Poor impulse control Increased risk-taking behavior Emotional Dysregulation, lowered affect Impaired interpretation of Social Cues Increased stress vulnerability Decreased motivation Increased obesity risk Metabolic Hypercholesterolemia DM2 Increased CV morbidity Non-medical use of stimulants Reduced physical activity PhysicalMental AcademicSafety

Academics Data from USAFA Policy Changes Starting the school day 50 minutes later has a significant positive effect on student achievement Improved performance is not just a “wake up” effect from later start. Improvement persists in all classes throughout the day. Carrell, Scott E., Teny Maghakian, and James E. West. "A's from Zzzz's? The causal effect of school start time on the academic achievement of adolescents." American Economic Journal: Economic Policy 3, no. 3 (2011):

Teen Safety Automotive Crash Rates o Crash rates reduced 65-70% (Wahlstrom et al, Univ. MN, 2014) o Crash rates reduced 16.5% while rest of state actually increased 7.8% over the same period. (Danner & Phillips, J. Clin Sleep Med, 2008)

Teen Injuries Less than 8 hours sleep 1.7 times more likely to suffer sports injury Risk increases 1.4 times for each year grade increase (7-12) o Milewski J Pediatr Orthop. 2014

ADOLESCENT SLEEP WORKING GROUP, COMMITTEE ON ADOLESCENCE and COUNCIL ON SCHOOL HEALTH Pediatrics 2014;134;642; originally published online August 25, 2014; DOI: /peds Aim for 8.5 – 9.5 hours of sleep Middle and high school start 8:30 a.m. or later Aim for 8.5 – 9.5 hours of sleep Middle and high school start 8:30 a.m. or later “The AAP is making a definitive and powerful statement about the importance of sleep to the health, safety, performance and well-being of our nation's youth,” “ By advocating for later school start times for middle and high school students, the AAP is both promoting the compelling scientific evidence that supports school start time delay as an important public health measure, and providing support and encouragement to those school districts around the country contemplating that change. Judith Owens, MD, FAAP, lead author of the policy statement

Ohio Schools and Cost-Savings or Cost-Neutrality in Moving toward Healthier Start Times (2013 data, per school websites) Hudson City Schools, Ohio: Suburban NE Ohio - total student enrollment: 4,700 4 elementary schools, 1 middle school, 1 high school Percentage of graduates attending college or university: 95% In 2010 school year: Moved high school from 7:30 to 8:00 and middle school from 7:20 to 7:50 am Saved money by moving from three bus tiers to two, consolidating runs, and switching to an external vendor Dublin City Schools, Ohio: Suburban Central Ohio (near Columbus) - student enrollment in excess of: 14,500 10th largest district in the state 12 elementary schools, 4 middle schools, 3 high schools Minority student population: 30.7% Average ACT score of 25.2 In 2011 school year: Moved middle school from 8:15 am to 8:43am, high school from 7:25 am to 8am The move was cost-neutral in relation to start times, but saved money due to other transportation changes made Kenston Local Schools, Ohio: Rural NE Ohio - total student enrollment: 3,140 3 elementary schools, 1 middle school, 1 high school Percentage of graduates attending college or university: 94% In 2012 school year: Moved middle and high school start times from 7:20 am to 7:50 am The end of the school day for middle and high school was moved to 5 minutes later The move was cost-neutral Westlake City Schools, Ohio: Suburban NE Ohio (Greater Cleveland Metropolitan Area) - student enrollment approximate: 4,000 4 elementary schools, 1 intermediate school, 1 middle school, 1 high school In top 4% of districts in state scorecard rankings In 2011 school year: Moved high school start times from 7:30 to 7:55am The move was cost-neutral Perrysburg Schools, Ohio: Suburban NW Ohio - student enrollment in excess of: 4,900 4 elementary schools, 1 junior high school, 1 high school Average ACT score 23.8 In 2011 school year: Moved high school from 7:40 to 8:00am, middle school from 7:25 to 7:45 am The move was cost-neutral Parma City School District: Suburban NE Ohio (Greater Cleveland Metropolitan Area) - total student enrollment: 11,470 8 elementary schools, 3 middle schools, 3 high schools In 2012 school year: High school moved from 7:35 to 8:10 am, middle school from 8:00 to 8:20 am Move was driven by financial considerations and building consolidation, not driven by the research, although the research was ‘not discouraging’ in decision-making processes