John Garcia, MDDiplomate, American Board of Sleep Medicine

Diplomate, American Board of Pediatrics

Improved Student Outcomes with Later High School Start Time

Disclosure Information

I have no financial relationships to disclose.

No Conflicts of InterestNo Corporate Affiliations

No Speakers Bureaus

I will not discuss off label use and/or investigational use in my presentation.

Objectives

Objectives:• Describe the hormonal changes at the root of the

delay in the sleep cycle understanding this as a biologic rather than social phenomenon.

• Describe 3 broad areas of improvement (outcomes) when total sleep time increases in teens.

• Be able to adapt the teens and sleep conversation to fit the individual with whom you are speaking.

Puberty and Melatonin Onset Phase: Hormonal Signal of Nighttime

Carskadon et al. NYAS, 2004

11pm

8pm

10pm

9pm

7pm

Homeostatic drive lessens in adol.

Species Manifesting Juvenile Phase Delay

• Homo sapiens (humans)• Macca mulatta (Rhesus monkeys)• Octodon degus (degu) • Rattus norvegicus (laboratory rat)• Mus musculus (laboratory mouse)• Psammomys obesus (fat sand rat)

• Take home point: Juvenile Phase delay is inherent to life on earth.

Hagenauer et al., Devel Neurosci, 2009

https://umconnect.umn.edu/p55411832/

Carskadon et al. Sleep, 1998

Summary of Process S Change

• Recovery sleep process does not change across adolescence– Need for sleep is stable

• Accumulation of sleep pressure slows– Staying awake longer is easier

• Result: late nights are easier to achieve but the same amount of sleep is needed

Thanks to Mary Carskadon for this slide

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Sleep during adolescenceSleep Requirement

AGE

Hou

rs

sleep debt accumulates and is often underestimated

SLEEP 2003;2:117-126

Cumulative sleep loss

Neu

robe

havi

oral

defi

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While neurobehavioral deficit in increasing, subjective sleepiness may plateau

Sub

ject

ive

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epin

ess

Carskadon, Pediatr Clin North Am, 2011

Sleep log; insufficient sleep

A sleep log is invaluable here. This person is not a short sleeper. If she were she would not need to sleep in on weekends.

Letter grades coded as 5 = B & C; 6 = B; 7 = B & A; 8 = A

Safety: car crashes are related to school start time

2007 20080

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Thanks to Kyla Wahlstrom , PhD for next 15 slides https://umconnect.umn.edu/p50372726/

<4 5 6 7 8 9 >100

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Mood: Risk of suicide attempt in teens is related to how much sleep they get

Pediatric Sleep Doctor Working with Parents and Schools

John Garcia, MD

A Story of a Success

• The outgoing administrator of my children’s school proposed that start time be changed from 840 to 730 AM.

• 800 emails were sent summarizing the research you have seen here today.

• There were 140 email responses supporting the continuation of the 840 AM start time. There were only 2 emails supporting the change.

• The administrator withdrew the proposal within a week.

Talking points for parents

• Children cannot adjust by going to bed earlier. The biological clock is genetically programmed to be ready to sleep at a particular time. Going to bed before the body is ready will not “recapture” the sleep lost by getting up an hour earlier.

• At puberty the sleep onset time is one hour later.

More talking points for parents

• There is no evidence of a net gain in access or performance in after school extracurricular activities when start times are earlier.

• Sleepy teens are not just sleepy in their first few classes. The cognitive and behavioral deficits persist until the sleep debt is paid. The perception of deficit has a ceiling though the consequences continue to accumulate.

Listening to stake holders

• Parents of younger children are worried about school-aged children waiting for the bus in the dark. – One response: a neighborhood cooperative

• Coaches want an earlier end to the academic day so that afternoon practice does not extend into the early evening.– One response: rested athletes are more successful

• Teachers want to beat rush hour traffic.– One response: The benefits to students may outweigh

the inconvenience.

Objective #1: Questions: Who is the messenger?

• Both the promise and problem of working in the field of sleep medicine is that no single specialty has all the answers. – Even within the relatively

narrow field of clinical pediatric sleep medicine in order to thrive I have to have nurture close relationships with pediatric pulmonologists, child psychiatrists, child neurologists and child psychologists.

Who is the messenger?

• Who is the provider that first encounters the sleep disorder?– Parent – Teacher– Psychologist– Peer– Coach– Physician

“Who’s on first?”, Abbot and Costello

Who or what is the target?

• The teen?– What are teens unique

liabilities/opportunities

• The interaction between provider and teen?– This is the interaction

that all of us here either support or perform.

The monkey wrench • The monkey wrench in the

method of policy creation is the misunderstanding that a punitive response can work.

• The punitive response may benefit someone (eg. Insurance companies in the case of the car wreck.)

• In addition to hurting the person or family that needs help, it feeds the illusion that something substantial has been accomplished.

The oil of integration

• The oil is:– Integrating persons with

neurologic differences including biologic clock disorders. The model of the Americans with Disabilities Act comes to mind.

– Improving communication between scientists, schools and policy makers.

Monkey wrench evolves to oil can

• Can we imagine a society where we a see a punitive consequence as a missed opportunity for the creation of policy?

• Can we see that when our patients or families are burdened a system of ineffective punishment is at work? An opportunity to change policy awaits us.

Monkey wrench evolves to oil can

• Reframing the conversation from language of a “character defect” or “laziness” to the refined use of neurologic vulnerabilities and diagnosis is a first step towards policy creation.– It is delayed sleep phase

syndrome not delayed “laziness” syndrome.

MOOD ACADEMICS DRIVING

INDIVIDUAL(teen)

implies fewer medical appts and better peer relationships

better job and college placement

Teens want to avoid personal injury

HOME(parent)

Less money spent on psychological and psychiatric copays

Less stress in the home

Few parents want a 19 year old living in their basement (joke)

Decreased car insurance payments and less money spent on auto repairs

SCHOOL(teachers)

Decreased security and psychological in-school counseling contracts

Nationally we are moving toward a model where teachers and schools are rewarded for academic achievement

?

NATIONAL(policy makers)

Decrease healthcare costs

Improved national educational outcomes

Decrease healthcare costs

Comments from children

• As my 12 y.o. daughter said, "We are not robots who you just program to wake up an hour earlier"

• What is wrong with them? Don't they read the studies? (quote from a 16 year old)