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ver the last two decades, researchers have established anincreasingly more nuanced understanding of adolescents’sleep demands, patterns, and underlying bioregulatoryprocesses.1,2 Simultaneously, with regard to perceived sleepneed, teachers, parents, and adolescents themselves haveconsistently indicated that teens get an inadequate amount ofsleep. In response to these findings, researchers and sleepclinicians have begun to assess a range of countermeasuresand interventional strategies aimed at improving teens’ sleepand daytime functioning.

Laboratory and field studies indicate that the biologicalneed for sleep (about 9 hours per night) does not changefrom ages 10 to 17 years. Indeed, older teenagers sleep morethan younger teens when given the opportunity in a labora-tory setting or on weekends, summers, and vacations.1

Numerous studies across a variety of geographic and cul-tural settings point out, however, that middle school andhigh school adolescents in the “real world” typically obtainless sleep than younger, elementary school-aged children.Also, the timing of sleep gets later as children enter and passthrough adolescence, a developmental period characterizedby staying up later at night and sleeping in later in themorning. This delay of sleep in adolescents is most obviouson weekend nights, whereas on weekdays their sleep pat-terns are largely determined by school start-time schedules.3-5

Survey results consistently indicate that middle and highschool students who start school at 7:15 AM or earlier obtainless total sleep on school nights due to earlier rise times incomparison to students at later starting schools.3-6

Imposition of early school start times for adolescents appearsto require teenagers to have bedtimes that are impracticaland/or infeasible, and, as a result, they have insufficient timefor sleeping.

Furthermore, insufficient sleep has serious emotional, behav-ioral, and cognitive consequences for adolescents. Sleepiness-related crashes are most common in drivers aged 16 to 25 years,particularly for boys.7 Cognitive function and psychomotor skillsare closely related to sleep, and laboratory studies have connect-ed sleep loss to significant decreases in children’s and adoles-cents’ performance.8-10 Similarly, findings from a variety of stud-ies that examined sleep and school performance indicate thatshortened total sleep time, erratic sleep/wake schedules, late bedand rise times, and poor sleep quality are negatively associatedwith academic performance for adolescents from middle schoolthrough the college years.11

AdolescentSleepUpdate

Narrowing the gap betweenresearch and practice.

B y A m y R . W o l f s o n , P h D

SCHOOL START TIMES AND SLEEPA number of school districts have responded to research

reports regarding the prevalence of inadequate sleep amongmiddle and high school students with a systematic counter-measure—delaying school start times. Other districts haveand continue to debate the issue.

A decade ago, Wahlstrom and colleagues, whose chief area ofexpertise is educational policy, compared more than 18,000high school students in the Minneapolis School District beforeand after the district’s school start time changed from 7:15 AM inthe 1996-97 school year to 8:40 AM beginning with the 1997-1998 school year.12,13 The researchers compared attendance,enrollment, grades obtained from official school records, andsleep patterns acquired from a self-report survey. They reportedseveral statistically significant results:

1. Attendance rates for students in grades 9 through 11improved;

2. The percentage of high school students continuouslyenrolled in the district or the same school also increased;

3. Grades showed a slight but not statistically significantimprovement; and

4. The students reported bedtimes similar to students inschools that did not change start times, obtaining nearly ahour more sleep on school nights during the 1999-2000school year.12,13

Similar findings were reported for middle school studentsin an urban New England school district. Seventh and eightgraders at a later-starting middle school (8:37 AM) reportedless tardiness, less daytime sleepiness, better academic per-

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Adolescent Sleep Update

formance, more school-night total sleep,and later rise times in comparison tomiddle school students at an earlierstarting school (7:15 AM).5

It is difficult to track just how manypublic school districts around the countryhave delayed the start of their middle andhigh schools in response to teenagers’sleep quantity and schedule needs. In astudy titled “A Survey of FactorsInfluencing High School Start Times,”Wolfson and Carskadon surveyed 345public high school personnel regardinghigh school start times, factors influenc-ing school start times, and decision-mak-ing around school schedules.14 Mostschools had not changed—or even con-templated changing—their school starttimes. Of those schools in which changeswere contemplated, 32% noted concernsabout teenagers’ sleep needs and about50% of the respondents endorsed possi-ble positive outcomes, such as lower tar-diness and absenteeism rates. Perceivedbarriers to changing school schedulesreported by this group included a sched-ule change’s impact on sports practices,after-school activities, and the to-and-

from-school transportation system.11

ADVOCACY AND RESEARCHSince the late 1990s, the independent

nonprofit National Sleep Foundation(NSF) has tried to track school start-timechanges as a part of its ongoing focus oneducating the public about adolescents’sleep needs. Specifically, in 2000 it estab-lished the Sleep and Teens Task Force,which is made up of researchers and cli-nicians in the field. That same year, thetask force published a report, AdolescentSleep Needs and Patterns, documentingexisting research about sleep-relatedissues affecting adolescents.15

More recently, as a way of advocatingfor sleep-friendly schools, NSF developeda tool kit to assist school professionals,parents, and teens in pushing for laterschool start times.16 The tool kit includesbackground information, advocacy strate-gies, school district case studies, sleepeducation materials, and sample schooldistrict resolutions. NSF has given outmore than 1,500 tool kit CDs, reportsDarrel Drobnich, senior director of gov-ernment and transportation affairs for the

NSF. However, it has been unable to trackthe use and impact of the tool kit any fur-ther. Unfortunately, there is no reportingmechanism through professional educa-tion organizations; however, according toinformal NSF data, the foundation esti-mates that close to 80 US school districtshave delayed the start of their highschools and more than 140 districts arecontemplating a change.

The districts range from large, urbanschool districts, such as Denver andMinneapolis, to smaller, suburban dis-tricts or towns, such as Wilton, Conn, orWest Des Moines, Iowa. The focus hasbeen primarily on high schools, so it isdifficult to estimate what percentage ofthese changes included middle schools.Moreover, a delay might be as short as7:15 AM to 7:30 AM versus 8:00 AM to9:00 AM. In addition, the 2006 NSF Sleepin America poll reported that, for mostsixth to eight graders, school starts at 8:00AM or later (69%). However, a little morethan half of the high school studentsreported that their classes start before8:00 AM (52%).17 Clearly, a more formal,empirically based reporting mechanism is

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needed to evaluate and track school start-time changes and related sleep educationrecommendations.

PREVENTIVE MEASURESAnother important countermeasure or

approach to the treatment of sleep prob-lems due to inadequate and irregular sleeppatterns in adolescents is to prevent theiroccurrence in the first place. Findingsfrom five large-scale studies document thatparent education may be the most eco-nomical and efficient strategy for treatingand preventing behavior-related sleepproblems in children.18-20 In general, par-ent education programs have targetedbedtime routines, consistent sleep sched-ules, and parental involvement in sleeponset and night wakings. Future programsshould consider targeting parents of olderchildren and adolescents. For example, ina needs assessment of inner-city middleschool-age children, young adolescentsseemed receptive to involving their par-ents in helping them decrease televisionviewing close to bedtime and in assistingwith bedtime routines.21

Previous research has demonstratedthat identifying teachable moments is ahigh priority for preventive/interventionprograms. Middle school is a key timefor the development of both positive andnegative health-related habits, such asfood likes and dislikes, exercise behav-iors, and drug experimentation.22-24

Preventive pediatric care, however, isunlikely as adolescents seldom see healthcare providers and report the lowest ratesof outpatient visits.25,26 In contrast, mostchildren and adolescents are in school,making it a natural setting for preven-tive/intervention programs.27

In recent years, a handful of sleep edu-cation programs have been created for ele-mentary school through college-age stu-dents. In Wolfson and Carskadon’s firstbell survey, approximately 50% of highschool respondents noted that sleep isincluded in their district’s high schoolhealth and/or biology course offerings.14

To date, however, the majority of curricu-la are didactic in format as opposed tointervention-oriented. Similarly, most ofthe programs have not been evaluated foreffectiveness and other outcome variables.Cortesi and colleagues evaluated theeffects of a 2-hour sleep educational pro-gram with a group of high school studentsin Italy.28 Targeted students and a compar-ison group were evaluated on their knowl-edge immediately following the course

and 3 months later. Both groups had poorbaseline knowledge of sleep, but the edu-cation group had an average 50% gain inpercentage of correct answers after thecourse as well as a 3-month retention ofinformation in comparison to the controlgroup. Similarly, Brown and colleaguesdeveloped a sleep education program forfirst-year college-age students (SleepTreatment and Education Program,STEPS) and found that students who par-

ticipated in the program reported signifi-cantly improved sleep quality and hygienepractices 6 weeks post-treatment.29

Currently, Wolfson and colleagues areevaluating the efficacy and effectivenessof the Young Adolescent Sleep-SmartPacesetter Program. This social learning-based approach focuses on changingbehavior and/or preventing problematicsleep/wake behaviors for young teenagers.Preliminary findings suggest that this pre-

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ventive/intervention approach is effectivein increasing total sleep time, developingmore consistent sleep schedules, andincreasing middle schoolers’ confidencein their ability to get enough sleep andkeep a healthy bedtime routine.30,31

A few examples of other sleep educa-tion programs include:

1. At the elementary school level, theNational Center on Sleep DisordersResearch at the National Heart, Lung,and Blood Institute (NHLBI) initiatedthe Sleep Well. Do Well. Star SleeperCampaign.32

2. The NSF PJ Bear Sleep for Kidsprogram.33

3. At the young adolescent level, theNational Space Biomedical ResearchInstitute with Baylor College of

Medicine developed From Outerspaceto Innerspace: Activities Guides forTeachers,34 which addresses the body’sbiological clock and sleep.

4. For high school students, theNHLBI developed the Sleep, SleepDisorders, and Biological Rhythms cur-riculum as a resource guide for teachers.35

POLICY ADVANCESAt a national and state policy level,

there have been a number of develop-ments. Following the convening of aWorking Group on Problem Sleepinessorganized by the National Institutes ofHealth’s National Center on SleepDisorders Research and the Office ofPrevention, Education, and Control, theNIH identified adolescents and youngadults (ages 12-25) as a population at highrisk for problem sleepiness based on “evi-dence that the prevalence of problemsleepiness is high and increasing in thesegroups, with particularly serious conse-quences.”36 More recently, in the NationalInstitute of Mental Health’s (NIMH)Blueprint for Change, NIMH discusses theserious emotional and behavioral healthconsequences of insufficient sleep amongadolescents and strongly states how sleepdeprivation, mood disturbance, impairedconcentration, and reduced self-regulatoryskills may lead to impaired functioning in

academic and social settings.37

At the congressional level, USCongresswoman Zoe Lofgren (D-Calif)proposed the “Zzzzz’s to A’s” bill.38 Thislegislation was to provide federal grantsof up to $25,000 to school districts tohelp cover the administrative costs ofadjusting school start times. At the statelevel, the Connecticut legislature has con-sidered a bill that would prohibit publicschools from starting before 8:30 AM.Also at the state level, in January, inresponse to the concern that young driv-ers are at higher risk for sleep/fatigue-related crashes, Massachusetts signedinto law the “Driver Education andJunior Operator’s Licenses” bill.39 Itrequires the formation of a special com-mission to study the impact of drowsy

driving on highway safety and the effectof sleep deprivation on drivers.

MESSAGES IN THE MEDIAArguably, over the last decade, there

has been a wealth of media coverage onteenagers’ lack of sleep. Although it is dif-ficult to quantify and evaluate, researchon adolescents’ sleep and the conse-quences of inadequate sleep has beencovered in a wide range of venues. First,the topic has been documented in thepopular media, including national andlocal newspapers, magazines, and televi-sion programs. Second, increasinglymore education, health, and medicalpublications (professional and lay level)have outlined the issues. Third, numer-ous news, foundation, medical school,education, health, teen, and parentingWeb sites and blogs discuss and promoteadolescent sleep needs, cover the latestresearch, raise important questions, andmake recommendations, largely based onempirical research.

Furthermore, the NSF is partneringwith clinical and academic sleep centersthroughout the United States andCanada (more than 800 to date) to com-bat sleep deprivation, fight sleep disor-ders, and educate the public about theimportance of sleep. As a part of theCommunity Sleep Awareness Partner

(CSAP) network, the NSF has focusedon children and adolescents.40

The question remains as to whetheradolescents (and the institutions they areconnected to, such as family, school, etc)are getting the message. The good newsis clearly that far more sleep resources areavailable to middle and high school stu-dents; however, serious concerns remain.

According to the NSF 2006 poll ofabout 1,600 adolescents and parents, themajority of US teenagers continue to getfar less sleep than they need, have poorsleep hygiene (irregular sleep schedules,televisions in bedrooms, caffeine use, etc),and experience serious consequences,such as sleepy-driver accidents, schoolabsenteeism, and diminished academicperformance. At this juncture, then, whatis needed? The following recommenda-tions are certainly not exclusive, but theyare crucial steps in improving the sleepingand waking lives of adolescents (as well asthe adults in their lives).

1. Parents and other adults inteenagers’ lives modeling adequate sleephabits.

2. Ongoing effort to delay the start ofmiddle and high schools with animproved system for tracking changes.

3. More community-research partner-ships that focus on adolescents’ sleepneeds.

4. Ongoing coverage of adolescentsleep research at professional meetings,both in the sleep field and in related dis-ciplines (psychology, education, pedi-atrics, social work, etc).

5. Legislation on teen work hours,driver education/drowsy driving, andschool start times.

6. Development and evaluation ofpreventive interventions and sleep edu-cation programs.

7. Increased federal and private fund-ing for basic and applied research initia-tives, as well as for education programsfocused on child/adolescent sleep needsand related behavioral outcomes.

Amy R. Wolfson, PhD, is professor of psychology atCollege of the Holy Cross in Worcester, Mass, andthe principal investigator of the Young AdolescentSleep-Smart Pacesetter Program funded by theNational Institute of Child Health and HumanDevelopment. She can be reached atsleepeditor@ascendmedia.com.

References are available with theonline version at

www.sleepreviewmag.com.

Imposition of early school start times for adolescents

appears to require teenagers to have bedtimes that are

impractical and/or infeasible, and, as a result, they have

insufficient time for sleeping.

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Overage

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