By Dr. Marvin Wang, M.D.
The statement emerged as a result of accumulating evidence showing that earlier school start times effectively restrict an adolescent’s ability to get regular healthful sleep.
The timing of the AAP’s statement came on the heels of another sentinel event in my family’s life. Just a month after its publication, my daughter started school. No big deal, except for the fact that she has never been to school before. Until this year, she was exclusively homeschooled here in Jamaica Plain, Massachusetts.
My wife and I didn’t have any major agenda driving this decision, other than the fact that we knew we could do it (we work part-time) and it seemed like it would be more family fun. The many details of our homeschooling adventures are really for another time, though.
The reason I even bring up the topic is that as a homeschooler, my daughter was able to wake up when she wanted to (usually within reason). On a regular day, she was used to getting up at 8:30ish (despite sometimes our having to pry her out later).
After a whole lifetime of this, imagine the draconian lifestyle shift of being asked to get up at 6 a.m. every weekday! This is the routine that is better known to most people as “going to school.” Now, let’s be clear about a few things: 1) our daughter wanted this. She asked to take the exam for the Boston Public Schools, in hopes of going to Boston Latin School, where she watched many of her friends attend; 2) she knew the early mornings were part of the routine; and 3) BLS actually has a relatively benign start time of 7:45 a.m., compared to many of its counterparts in the district and the state.
So what’s all the fuss? It cannot be a novel idea to most adults that the typical school teenager is a surly blob on most weekday mornings. Should we be surprised to learn that we have been breeding generations of sleep-deprived adolescents? Should we, as educators, parents and “concerned citizens” be worried about this?
First, let's look at what's new since the AAP statement came out.
Indeed, the movement is picking up steam in some parts of the country, as whole districts have approved later start times. In Massachusetts, districts like Sharon, Easton, Duxbury and Nauset have done so.
And there are some new studies corroborating the AAP’s stance:
In looking at the neurobehavioral issues in teens, it turns out that just one night of sleep deprivation in an adolescent has marked worsening of sustained attention, reaction speed, cognitive processing speed and subjective sleepiness. When the sleep was restored, the teens were able to significantly improve all their cognitive abilities.
One study showed that sleep restricted teens (average of five hours/night) were more likely to be lower academic quartiles than those who slept more (average 6 ½ hours/night…which is still two hours less than optimal!). But looking at the results, one also finds that the perceived sleepiness among the sleep restricted group was at least twice that the sleep appropriate group.
For those who say that these kids can just get their sleep back over the weekend, the same study shows that the sleep restricted group tended to sleep almost 10 hours per weekend night on average, compared to 7 ½ hours per weekend night for a sleep appropriate teen. This means that the sleep restricted teen is oversleeping four hours per weekend night on average.
So is that a big deal? This study confirms previous notions that the more a teen oversleeps, the worse the average academic performance is seen. This drop in performance is seen when the oversleeping goes over two hours per weekend night.
Perhaps the poor academic performance has something to do with the result of poor sleep. In the AAP statement, they already identify increased mood and behavioral issues with decreased sleep. In this study, researchers were able to identify that the weekend “oversleepers” were more likely to have poor academic performance, and were more likely have suicidal tendencies.
Most parents don’t even think that their kid is sleep deprived, despite seeing the results every weekday morning. In this survey, teens and their parents were asked to complete a sleep diary. Upon completion, only 23 percent of the teens self-reported that they had a sleep issue, when the study diaries revealed that at least 66 percent had sleep problems. As well, of the same cohort, only 14 percent of the parents thought their kid had a sleep issue.
And while some school districts are moving ahead on the issue, many are not, so it's worth reviewing the arguments in support of the later start time.
The Medical Issues
Among the many changes associated with puberty, one ubiquitous effect is a shift in the adolescents’ daily clock. Whereas most adults will naturally feel the need to sleep around 9-10 p.m., and wake closer to 5-6 a.m., the teen’s body wants to go to sleep closer to 11 p.m., and wake around 7-8 a.m.
There’s lots of real physiological evidence demonstrating how teens just cannot fall asleep before 11 p.m., even when they are sleep deprived. You may have heard about the hormone Melatonin, which is one of the body’s chemical signals telling you to begin the sleep routine. In teens, we see that the regular Melatonin surge occurs several hours later at night compared to older adults as well as younger kids.
That’s why the argument, “Well, why don’t you just put kids to bed earlier?” doesn’t carry much weight. When you biologically push the “start” time later into the evening, and environmentally push the “end” time earlier in the morning, the result is a sleep restricted kid.
Is this a problem? It turns out that several decades worth of research has shown that sleep deprivation among adolescents (and the studies specify adolescents) causes a whole host of “badnesses.” From the obvious (sleepy during school, increased tardiness and absences, poor attention in class), to the downstream effects of the obvious (increased depression, anxiety, worsening of ADD symptoms), and to the more serious medical issues (increased risk of obesity leading to type II diabetes), the effects of sleep loss among teens are becoming more evident.
Even more abstract downstream effects are seen — like car crashes. When a school system switches to a later start time, they witness a 70 percent decrease in teen-related auto crashes. Unto itself, that’s pretty significant.
But most parents want to know what effect this has on their child’s performance in school, right?
The bottom line is that academics suffer when a teen is sleep deprived (from test scores, to attendance, to grades and to learning retention) and it improves (albeit the research so far says only modestly) with sleep adequacy. For those who are wondering if there are actually references for all these studies, most of the best, current literature on everything I’ve mentioned is referenced in the policy statement from the American Academy of Pediatrics.
Who wants to prevent kids from getting sleep?
Yeah, I know that title sounds really nasty, but I can’t get around it any other way. If you knew that kids were systematically being sleep deprived, knew that there were consequences behind it, and knew that they would truly benefit from the change towards more sleep, why would you be against such a change? Who, indeed? I think I have narrowed it down to several factions.
The typical argument is that if you end later in the day, that means that kids will be getting back home later after athletics practice. A second issue is that some sports depend on outdoor sun for their practice. Let’s take BLS golf as an example. They have to commute after school to golf facilities. Since so much of the school year has a sunset time typically at 4-4:30 p.m., that really limits the amount of time they can practice outdoors. I do sympathize with these practical issues. I do try to see a bigger picture, though. If you maintain a method that defeats athletic performance, why wouldn’t you change the method?
There is essentially a holy trinity for athletic performance — equipment, diet and training. Equipment is dependent upon the school’s budget; I can’t really speak toward that. Diet is under the control of the individual athlete and his/her family. Training, although affected in large part by the athletes and their coaches, has an unsung hero.
Research over the last decade has really shined the light on rest and recovery as a major component to muscle development. When you train, you break down the muscle used for that task. The goal is that when the muscle repairs itself, it will actually build up more tissue than was previously there. But the ability to rebuild muscle requires a mandatory recovery time. If the athlete does not get enough recovery (read: sleep), you’re basically undoing all your training. You’re effectively going through a vicious cycle of breaking down muscle from training, then maintaining that destruction by not getting enough rest. So, if you believe the idea that teens are being sleep restricted due to the earlier start time, you should also make the same conclusion that the sleep-deprived teen athlete is being held back from his/her actual potential.
The traditional argument from the teachers’ union has involved resistance to changes to their contracts. Here, I am at the mercy of the policymakers and the lawyers. If one shifts the time, but maintains the same total working time, I’m not sure if there is a major bureaucratic hurdle. And, there are perhaps more issues involved. But I find it remarkably difficult to find representatives who will even return my emails…
As mentioned before, the traditional method that most school districts employ involves two to three trips per bus per morning, where older kids are picked up first, dropped off, and then the same bus will return to the same spot to pick up the younger kids.
However, when schools shift toward later start times for high schools, they end up consolidating shifts, and the data has shown that these districts fairly unanimously save money and drive time compared to their traditional multi-shift method.
In our case at BLS, it seems like it might actually be simpler. Boston Public Schools just decreed this year that seventh graders and up would no longer be offered school bus transportation, and be shifted to MBTA busing. There are some exceptions to this, but at BLS, just about all the kids are coming in by MBTA or an MBTA charter. So it might be less of a contentious issue for us, specifically.
As I said, it seems like we’ve been on a 7:30 a.m. high school start time in America since Reconstruction. Some would say, “Well, we’ve been doing this for years, heck, I did it when I was a teen, and we seem to be doing fine.” Why do the proverbial fix for something that presumably is “not broke”?
I like using the analogy of medical residency training back in the “good ol’ days.” I trained here in Boston in the early '90s, which I now admit really dates me. The norm was being on call every third or every other night, and it was typical to be in the hospital for over 100 hours a week. It was soul-crushing, but the justification had always been that same argument by the older generation: we did it, we did fine, you should do it.
Thankfully, data coming out just about that time revealed that, controlling for other factors, patients suffered from caregiver mistakes due to resident fatigue. This helped fuel the overhaul all U.S. resident training over the last 15 years to restrict resident work hours.
So, in the case of later middle/high school start times, we have the data showing kids are suffering. We have data showing that a simple change can improve their lives. What’s even more interesting is that the same data shows that there is no downside to this. What will it take, then, to hit the tipping point of public awareness on this topic?
So What's Next?
I’m a pediatrician, and really, all I know is how to take care of patients in the hospital. Having never been an “advocate” before, I’m diving into the world of policy by the "flooding" method — i.e., read up on the Internet resources, make lots of calls, redundant emails, sit in on meetings, and try to be as charming as possible without appearing ignorant or preachy.
I won't take the space here to detail what it takes to make changes within the Boston Public School system except to say this:
At the moment, my mission is to find the representatives from the union to find out if I can help them understand that a later start time might make their lives easier, without the conflict. The unfortunate thing is that it appears to be very difficult to find union reps who will speak with parents. Even after going through a Boston Teachers Union “parent liaison,” I was politely told that she would not give me any contacts.
Trying to go to the BPS school board or even the mayor’s office appears futile. No one from these entities will return any of my emails or my calls.
But that's my current reality. It’s slow going, but as the accidental advocate, I will learn how to keep digging away to find more support for the greater glory of improving adolescent sleep.
Marvin Wang, M.D., is director of newborn nurseries at Massachusetts General Hospital and assistant professor of pediatrics at Harvard Medical School.