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and by a longer time to fall asleep after nights; indeed, the average amount of studies, underscoring how chronic
being awake for 14.5 to 18.5 hours in school night sleep obtained by high sleep restriction can undermine health
postpubertal versus prepubertal teen- school seniors was less than 7 hours. (Table 1).40,41
agers.10 Thus, these 2 factors typically In this same survey, however, 71% of
make it easier for adolescents to stay parents believed that their adolescent IDENTIFYING SOLUTIONS: THE
awake later. At the same time, several was obtaining sufficient sleep. This ROLE OF DELAYING SCHOOL START
studies from different perspectives in- mismatch indicates a significant lack TIMES
dicate that adolescent sleep needs do of awareness among adults regarding
This “epidemic” of delayed, insuffi-
not decline from preadolescent levels, the extent of adolescent sleep loss. As
cient, and erratic sleep patterns
and optimal sleep for most teenagers is a result, many middle and high school
among adolescents and the accom-
in the range of 8.5 to 9.5 hours per students are at risk for adverse con-
panying negative effects on adoles-
night.5,11,12 On a practical level, this re- sequences of insufficient sleep, in-
cent health and well-being highlight
search indicates that the average teen- cluding impairments in mood, affect
the importance of identifying poten-
ager in today’s society has difficulty regulation, attention, memory, behav-
falling asleep before 11:00 PM and is best ior control, executive function, and tially modifiable factors. The quest to
suited to wake at 8:00 AM or later.4,12,13 quality of life (Table 1).21–26 reduce the high cost of sleep loss in
adolescents is not only an important
The sleep–wake changes that flow Insufficient sleep also takes a toll on
public health issue but one of para-
from this biological maturation may academic performance. In the National
mount importance to educators, pe-
enable teenagers’ interactions with Sleep Foundation poll cited previously,20
diatric health care providers, and
such environmental factors and lifestyle/ 28% of students reported falling asleep
social demands as homework, extra- in school at least once a week, and TABLE 1 Impact of Chronic Sleep Loss in
curricular activities, after-school jobs, more than 1 in 5 fell asleep doing Adolescents
and use of technology.14–16 As a result, homework with similar frequency. Physical health and safety
most teenagers stay up late on school Many studies show an association be- Increased obesity risk
nights, getting too little sleep, and then tween decreased sleep duration and Metabolic dysfunction (hypercholesterolemia,
type 2 diabetes mellitus)
sleep in on weekends to “catch up” on lower academic achievement at the Increased cardiovascular morbidity
sleep. Although this weekend over- middle school, high school, and college (hypertension, increased risk of stroke)
sleeping can help offset the weekly levels, as well as higher rates of absen- Increased rates of motor vehicle crashes
(“drowsy driving”)
sleep deficit, it can worsen circadian teeism and tardiness and decreased
Higher rates of caffeine consumption; increased
disruption and morning sleepiness at readiness to learn (Table 1).17,27–30 risk of toxicity/overdose
school.9,17,18 An increased prevalence of anxiety and Nonmedical use of stimulant medications;
diversion
mood disorders has also been linked Lower levels of physical activity
The Extent and Effects of to poor quality and insufficient sleep in Mental health and behavior
Adolescent Sleep Loss adolescents.31–33 Other specific health- Increased risk for anxiety, depression, suicidal
ideation
Given both biological demands and related effects of sleep loss include Poor impulse control and self-regulation;
today’s sociocultural influences, it is increased use of stimulants (eg, caf- increased risk-taking behaviors
not surprising that many studies have feine, prescription medications) to Emotional dysregulation; decreased positive
affect
documented that the average adoles- counter the effects of chronic sleepi- Impaired interpretation of social/emotional
cent in the United States is chronically ness on academic performance.34,35 cues in self and others
sleep deprived and pathologically Adolescents are also at greater risk of Decreased motivation
Increased vulnerability to stress
sleepy (ie, regularly experiencing levels drowsy driving–related crashes as a Academics and school performance
of sleepiness commensurate with result of insufficient sleep.36,37 Chronic Cognitive deficits, especially with more complex
those of patients with sleep disorders sleep restriction increases subsequent tasks
Impairments in executive function (working
such as narcolepsy).19 For example, risk of both cardiovascular disease
memory, organization, time management,
a recent National Sleep Foundation and metabolic dysfunction, such as sustained effort)
poll20 found that 59% of sixth- through type 2 diabetes mellitus.38,39 An asso- Impairments in attention and memory
eighth-graders and 87% of high school ciation between short sleep duration Deficits in abstract thinking, verbal creativity
Decreased performance efficiency and output
students in the United States were and obesity in children and adoles- Lower academic achievement
getting less than the recommended cents has been demonstrated in sev- Poor school attendance
8.5 to 9.5 hours of sleep on school eral cross-sectional and prospective Increased dropout rates
subject-specific standardized tests (ie, assessed as an outcome in previous 2 adjacent, demographically similar
math, English) correlated with whether research, later start times might in- cities, there were significantly in-
the student was scheduled for that crease the likelihood that students will creased teen (16- to 18-year-olds) crash
subject during first period.56 Similarly, eat breakfast before school and thus rates over a 2-year period in the city
first-year Air Force Academy students further enhance their readiness to with earlier high school start times
assigned to start classes after 8:00 AM learn.57 Finally, improvements in teacher (2007: 71.2 per 1000 vs 55.6 per 1000;
(compared with before 8:00 AM) per- satisfaction linked to increased sleep 2008: 65.8 per 1000 vs 46.6 per 1000
formed better in their first-period offers yet another potential mechanism [P < .001]), and teen drivers’ morning
course and, in addition, had a 0.15 for classroom enrichment. crash peaks occurred 1 hour earlier.61
SD increase in performance across all Several other outcome measures ex- Finally, the recent study by Wahlstrom
of their courses.44 In a study focusing amined in these studies also deserve et al54 found a crash rate reduction in
on middle school students,45 a 1-hour emphasis. In the study by Owens et al,53 16- to 18-year-olds of 65% and 70%,
later shift in school start times was there were significantly fewer students respectively, in 2 of the 4 high schools
associated with an increase in read- self-reporting symptoms of depressed studied; notably, the high school with
ing test scores by 0.03 to 0.10 SD and mood as well as improved motivation the latest start time (Jackson Hole, WY)
in math test scores by 0.06 to 0.09 SD. after the start time delay. In a more had the largest decline in car crashes.
The author concluded that an increase recent study, also conducted in an in- Although considerable empiric sup-
in start times by 1 hour would result dependent school setting, a 25-minute port exists for the concepts that early
in a 3 percentile point gain in both delay in start time was associated not school start times are detrimental to
math and reading test scores for the only with increased sleep duration and adolescents’ health and well-being
average student. Furthermore, stu- decreased daytime sleepiness but also and that delaying school start times
dents performing in the lower end of with less self-reported depressed mood.58 results in substantive and sustained
the test score distribution seemed to Although more research is needed, benefits to students, the ongoing de-
benefit most, with gains roughly twice given the mounting evidence sup- bate among school districts in the
those in above-average students, and porting a bidirectional link between United States regarding the wide-
the effects persisted into high school. sleep patterns and problems and spread institution of later start times
In a more recent middle school study mood disorders in this population59 for middle and high schools continues
by the same research group, the (including an increased risk of sui- to spark controversy. Moreover, the
results suggested that moving school cidal ideation57), countermeasures logistical considerations in imple-
start later by 1 hour can have an that could potentially mitigate these menting delayed school start times in
impact on standardized test scores effects have important public health middle and high schools are far from
comparable to decreasing the class implications. trivial. Wolfson and Carskadon62 sur-
size by one-third. Finally, in a recent 3- Furthermore, adolescents are at partic- veyed 345 public high school personnel
state study, 5 of the 6 high schools in ularly high risk of driving while impaired regarding their perspective on high
which grade point average was by sleepiness, and young drivers aged 25 school start times, factors influencing
assessed showed a significant pre– years or younger are involved in more school start times, and decision-making
post increase in grade point average than one-half of the estimated 100 000 around school schedules. Most respon-
in core subjects of math, English, police-reported, fatigue-related traffic dents at that time had not changed or
science, and social studies.54 crashes each year. 60 Danner and contemplated changing their school
Finally, there may be additional health- Phillips52 examined the relationship start times. Perceived barriers to
related and other benefits associated between automobile crash records for changing school schedules commonly
with delays in start time. For example, students 17 to 18 years of age and high endorsed included curtailed time for
students in the independent school school start times. Car crash rates for athletic practices and interference
study cited previously53 reported sig- the county that delayed school start with scheduling of games, reduced
nificantly more satisfaction with their times decreased by 16.5% over the 2 after-school employment hours for
sleep. In addition, class attendance im- years before and after the school- students, challenges in providing child
proved, as did health-related variables, start change, whereas those for the care for younger siblings, adjust-
including fewer visits to the campus state as a whole increased by 7.8% ments in parent and family schedules,
health center for fatigue-related com- across the same time period. In an- potential safety issues, effects on
plaints.53 Although not specifically other recent study conducted in sleep duration in younger children if
3. Educational interventions for par- account in setting a start time that COMMITTEE ON ADOLESCENCE, 2012–
ents and adolescents as well as allows for adequate sleep oppor- 2013
Paula K. Braverman, MD, FAAP, Chairperson
the general public should be devel- tunity for students. Additional in-
William P. Adelman, MD, FAAP
oped and disseminated by the Amer- formation regarding opportunities, Cora C. Breuner, MD, MPH, FAAP
ican Academy of Pediatrics and challenges, and potential solutions David A. Levine, MD, FAAP
other child and sleep health advo- involved in changing school start Arik V. Marcell, MD, MPH, FAAP
cacy groups. Content should include times may be found at: http://www. Pamela J. Murray, MD, MPH, FAAP
Rebecca F. O’Brien, MD, FAAP
the potential risks of chronic sleep sleepfoundation.org/article/sleep-
loss in adolescents, including de- topics/school-start-time-and-sleep; LIAISONS
pressed mood, deficits in learning, http://schoolstarttime.org. Loretta E. Gavin, PhD, MPH – Centers for Disease
attention and memory problems, 5. Pediatricians should routinely pro- Control and Prevention
poor impulse control, academic per- Rachel J. Miller, MD – American College of
vide education and support to Obstetricians and Gynecologists
formance deficits, an increased risk adolescents and families regard- Margo Lane, MD – Canadian Pediatric Society
of fall-asleep motor vehicle crashes, ing the significance of sleep and Benjamin Shain, MD, PhD – American Academy
and an elevated risk of obesity, hy- healthy sleep habits as an impor- of Child and Adolescent Psychiatry
pertension, and long-term cardiovas- tant component of anticipatory
cular morbidity. Information should STAFF
guidance and well-child care. In Karen Smith
also be included about the potential particular, pediatricians should James Baumberger
utility of systemic countermeasures, endorse parental involvement in
including delaying school start setting bedtimes and in supervis- COUNCIL ON SCHOOL HEALTH
times, in mitigating these effects. Fi- ing sleep practices, such as social EXECUTIVE COMMITTEE, 2012–2013
nally, educational efforts should also Cynthia D. Devore, MD, FAAP, Chairperson
networking and electronic media
Mandy Allison, MD, MSPH, FAAP
emphasize the importance of behav- use in the bedroom; for example, Richard Ancona, MD, FAAP
ior change on the individual level pediatricians could recommend Stephen E. Barnett, MD, FAAP
and the personal responsibility that to parents that they establish Robert Gunther, MD, FAAP
families and students themselves a “home media use plan” and en- Breena Holmes, MD, FAAP
Marc Lerner, MD, FAAP
have in modifying their sleep habits. force a “media curfew.” Adoles- Mark Minier, MD, FAAP
4. Pediatricians and other pediatric cents should be regularly queried Jeffrey K. Okamoto, MD, FAAP
health care providers (eg, school regarding sleep patterns and dura- Thomas Young, MD, FAAP
physicians, school nurses) should pro- tion and counseled about the risks
vide scientific information, evidence- of excessive caffeine consumption, FORMER COUNCIL EXECUTIVE
COMMITTEE MEMBERS
based rationales, guidance, and misuse of stimulant medications Jeffrey H. Lamont, MD, FAAP
support to educate school admin- as a countermeasure to sleepi- Robert D. Murray, MD, FAAP, Chairperson
istrators, parent-teacher associa- ness, and the dangers of drowsy Lani S. M. Wheeler, MD, FAAP
tions, and school boards about the driving.
benefits of instituting a delay in LIAISONS
Mary Vernon-Smiley, MD, MPH – Centers for
start times as a potentially highly LEAD AUTHOR Disease Control and Prevention
cost-effective countermeasure to ad- Judith A. Owens, MD, MPH, FAAP Carolyn Duff, RN, MS, NCSN – National Associ-
olescent sleep deprivation and sleep- ation of School Nurses
iness. In most districts, middle and CONTRIBUTING AUTHORS Linda Grant, MD, MPH – American School Health
(ADOLESCENT SLEEP WORKING Association
high schools should aim for a start-
GROUP) Veda Johnson, MD – National Assembly on
ing time of no earlier than 8:30 AM. School-Based Health Care
Rhoda Au, PhD
However, individual school districts Mary Carskadon, PhD
also need to take average commut- Richard Millman, MD STAFF
ing times and other exigencies into Amy Wolfson, PhD Madra Guinn-Jones, MPH
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located on the World Wide Web at:
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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since . Pediatrics is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois,
60007. Copyright © 2014 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: .