THE IMPACT OF SCHOOL START TIMES ON ADOLESCENT HEALTH AND ACADEMIC PERFORMANCE

Introduction In the early 1990s, a team of researchers lead by Brown Universitys Mary Carskadon determined that circadian biology drives the delayed sleep-wake patterns of adolescents. (1) Pubertys onset marks the beginning of a phase shift, with adolescents going to bed later and rising later than younger children. (2, 3, 4) Typically adolescents are unable to fall asleep at earlier times and sleep in later to get the 9 (5) hours of sleep they need. (2, 3, 6, 7, 8, 9) In 1994, physicians began advising school leaders to eliminat[e] early starting hours for teenagers[.] (10) Sleep experts urge a delay in morning classes until 8:30 a.m., or later, for middle and high school students. (2, 11, 12, 13, 14, 15) Few administrators have listened, (12) instead adhering to school schedules described by preeminent scientists as abusive, (16) nonsense, (17) deleterious, (18) cruel, (19) and nuts. (20) Most U.S. high schools schedule classes during the 7 oclock hour, (12, 21, 22, 23) while melatonin still pressures adolescents to sleep. (3, 24) The vast majority of teenagers attending early starting schools meet the morning bell in a sleep-deprived state. (2, 6, 8, 12, 23, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39) The consequences of this sleep deprivation are severe, impacting adolescents physical and mental health, as well as daytime functioning. (40) Students at later starting schools get more sleep, (4, 13, 30, 37, 41, 42, 43) perform better academically, (13, 24, 44, 45) have significantly fewer automobile accidents, (31, 46) report greater motivation (41) and less depression, (3, 37, 41, 47) experience fewer physical health difficulties, (37, 41) are less likely to be tardy or truant, (2, 30, 41, 44, 47, 48) demonstrate better performance in attention level, impulsivity, and rate of performance[,] (13) and, according to Brookings Institute economists, will likely earn significantly more money as adults when school begins at roughly 9 a.m. (49) Policymakers may eventually decide when the school day begins. (50, 51) Until then, at least during the school year, adolescent sleep sufficiency, a point of concern for the CDC (18, 26, 52, 53, 54) and the National Institutes of Health, (55, 56, 57) will substantially be determined by the whims of local school boards. (58)

This paper is updated weekly here -- http://schoolstarttime.org/; a three-page summary is available here (pdf).

I.

The Prevalence of Restricted Weeknight Sleep Among Adolescents

Almost all teenagers in this country are sleep-deprived. (99)---Maida Chen, M.D., Assistant Professor of Pediatrics, University of Washington School of Medicine, Assistant Director, Pediatric Sleep Disorders Center, Seattle Childrens Hospital. The great majority of high school students are getting insufficient sleep. (25, 26, 27, 100, 101) The 2011 National Sleep Foundation poll found only 14% of teenagers between the ages of 13 and 18 report getting nine or more hours of sleep on weeknights. (25) A 2010 study published in the Journal of Adolescent Health found that nationwide, on an average school night, 68.9% of students reported insufficient sleep (9). (26) The 2007 Youth Risk Behavior Survey of the Centers for Disease Control and Prevention (CDC) found that on weeknights, 31.1% of U.S. students reported getting 8 or more hours of sleep; 42% of ninth graders did so versus only 22% of 12th graders. (100) The 2006 National Sleep Foundation poll found only one in five adolescents get the recommended 9 hours of sleep per night. (101) Studies have shown sleep deficiency on school nights as prevalent for the better part of the last three decades. Researchers comparing data from 1981 and 20032006 found that bed times and wake times were similar, with teens averaging 8-8 hours sleep on school nights. (28) In a 1994 survey of high school students, 26% reported sleeping less than 6.5 hours on school nights, while only 15% reported sleeping 8.5 hours or longer. (55) In 2002, teenagers averaged 7.5 hours sleep on school nights, with a quarter of them getting only 6.5 hours per night. (102) Scientists writing in the June 2005 issue of Pediatrics observed, Both shortterm and long-term strategies that address the epidemic of sleep deprivation among adolescents will be necessary to improve health and maximize school performance. (6) In 2008, Norwalk Hospital sleep experts noted that the pattern of rising sleep debt during the week followed by weekend catch-up still leaves most teens sleep-deprived by an estimated 10 hours sleep per week. (2) In 2009, researchers again commented, Sleep deprivation among adolescents is epidemic. (103) Sleep scientists have uniformly concluded, Sleep deprivation among adolescents appears to be, in some respects, the norm rather than the exception in contemporary society. (27) Because of a multitude of intrinsic and environmental factors, adolescents are particularly vulnerable to disturbed sleep, and are one of the most sleep deprived age groups in the country. (40) It has been shown that adolescents increased sleepiness is similar to the clinical level of sleepiness presented by patients with severe sleep disorders. (104)

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Multiple factors contribute to sleep deficiency in teens, including electronic devices, jobs, erratic sleep schedules, caffeine, social and school obligations. (21, 29, 105, 106, 107, 108) Restricted sleep, however, is primarily limited to school nights, rather than weekend nights, with students losing up to 2 hours of sleep after the start of school. (2, 6, 21, 22, 26, 28, 29, 30, 55, 102, 109, 110) The consequences of this sleep deprivation are severe, impacting adolescents physical and mental health, as well as daytime functioning. (40) Sleep deficiency in adolescents is associated with: profoundly impaired learning capacity, memory, and alertness (11, 21, 27, 29, 111, 112, 113,114, 115, 116, 117)

depression, anxiety, fatigue (29, 118, 119) increased risk of suicidal ideation and completed suicide (53, 120, 121, 122, 123, 124) increased frequency of automobile accidents (31, 46) decreased athletic and motor skills (125, 126) excessive weight gain (127, 128, 129, 130) increased likelihood of risk-taking behaviors, including drug or alcohol use (53, 131, 132) increased likelihood of criminal conduct (133) physical, psychological, or social difficulties (134, 135, 136) elevated blood pressure (137) interference with secondary brain development, (138, 139) etc. These findings generally appear to apply equally to young adults, (24, 40, 136, 140) and, with the obvious exception of driving accidents, to middle school children as well. (22, 23, 30, 44) In light of these myriad negative effects on adolescent health and well-being, the identification of potentially modifiable factors that escalate the risk of insufficient sleep in this population is an important public health issue. (41) The vast majority of adolescents do not get enough sleep. Research has shown that the average teenager needs 9 to 9 hours of sleep a night. This is not all that much less than school-aged children need. However, the average amount of sleep that teenagers get is about 7 hours on school nights. Even on weekends and holidays, when they try to catch-up, teenagers average just 9 hours of sleep. This leads to teenagers missing an average of 2 hours of sleep per night, and it accumulates over time. (Mindell & Owens, Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems (Lippincott Williams & Wilkins, 2nd ed. 2010) p. 258.) This two hour discrepancy between weekend and school-night sleep has caused researchers to consider the relationship between pedagogical structures and adolescent biology. (2, 5, 6, 21, 23, 24, 26, 30, 31, 41, 44, 46, 101, 115, 116, 131, 138, 141)

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II.

The Basics of Adolescent Sleep Biology

Sending kids to school at 7 a.m. is the equivalent of sending an adult to work at 4 in the morning. (179) ---William Dement, M.D., Sc.D., Ph.D., Professor of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Division Chief, Stanford University Division of Sleep. In todays society, persevering through tiredness is often considered a badge of honour. (180) Functioning while sleep deprived shows the ability to endure hardship. (181) Historically, many members of the military view sleep as an indulgence; sleep deprivation in the interest of duty is even revered. (182) Diminished sleep, however, is a stressor which may adversely affect the morale or psychological well-being of even highly-trained military personnel. (183) Adolescents represent a population far more vulnerable to the effects of restricted sleep. (2, 5, 6, 21, 29, 40, 53, 55, 107, 131) Most adolescents rise between 5 a.m. and 6:30 a.m. to meet the morning school bell, essential training, some believe, for the real world. (184) While many adults in the real world start work early, many start considerably later than the average high school student. Recent census data reflect that roughly 30 percent of adults begin their morning commute after 8:00 a.m. (185) College students may get underway even later. In the Fall of 2010, for example, fewer than 2 percent of undergraduate courses at the University of Michigan started at 8:00 a.m. or earlier, and roughly 85 percent of classes started at 9:30 a.m. or later. (49) Until reaching the age of majority, adolescents are judged as too young to vote, sit as jurors, or join the armed forces, but old enough to rise while much of the world is still sleeping.(25)

The hour when the school day begins is the factor with the biggest impact on adolescent sleep sufficiency, (28) a point seldom considered by those preparing students for the real world. (12) Professor of Neurology and Director of the Minnesota Regional Sleep Disorders Center, Mark Mahowald, explains: All of the research that has been done shows that older adolescents need more sleep than younger ones. They fall asleep later and wake up later to get the sleep they need. Despite these two facts, almost all districts start the senior high schools first. Were sending them to school during the last one-third of their sleep cycles. Its comparable to adults getting up at 3 a.m. or 4 a.m. You wouldnt want to be making important decisions at that hour. I think its nuts. The sleep deficit builds up until they fall asleep at school or driving. (20, italics added.) In adults, shift work desynchronizes sleep cycles, resulting in sleep loss, and, in some instances, serious adverse health consequences. (186, 187, 188) Sleep cycle disruption, a feature of early school start times, and the attendant restricted4

sleep, (20, 23) are similarly closely associated with serious health-risk consequences among adolescents, except that these individuals are still developing, (2) their mortality/morbidity is increasingly implicated, (31, 46, 53, 120) and learningostensibly the primary purpose of educationis diminished. (2, 11, 13) While younger adolescents (i.e., middle school children) may be less likely than secondary school students to draw an early start time, (1, 121) those who do experience outcomes similar to those found among their older peers. (13, 23, 30, 44) As will be discussed, there are at least three significant biological factors to consider when evaluating the confluence of start times and adolescent sleep requirements: the essential/restorative value of sleep, (189, 190) adolescent circadian timing, (1, 103, 191) and the increased susceptibility in this population to the negative effects of sleep loss. (2, 5, 6, 21, 29, 40, 53, 55, 107, 131, 192) A. Sleep Needs/Sleep Loss as a Stressor Sleep is vital to your well-being, as important as the air you breathe, the water you drink and the food you eat. (219)---Nelson L. Turcios, M.D., Pediatric Pulmonologist. Animal studies have demonstrated that sleep properly belongs in Maslows hierarchy of physiological needs as indispensable to survival. (189, 190) Sleep is not some biological luxury. (220) Sleep is biologically obligatory. (5) Animals deprived of sleep die.(189, 220)

For adolescents, the National Sleep Foundation defines sleep as insufficient if 9 hours per night. (26) Carskadon and Wolfson point to ~9.2 hours of sleep as optimal and ~8.5 hours as adequate for this population. (12) Older adolescents require 9-10 hours. (2) Early sleep research suggested that after birth, sleep requirements declined during childhood development, leveling off at eight hours during puberty. (2) Research over the past thirty years, however, has demonstrated that the number of sleep hours required during the explosion of growth and other body changes of puberty remains at nine hours or more throughout adolescence. (2) Mere rest does not create the restorative state of having slept. [] The fundamental difference between sleep and a deeply relaxed wakefulness is that sleep involves dropping into a state with a relative loss of awareness of and responsiveness to the external world. This state of unresponsiveness appears to be necessary for the restorative processes that occur during sleep to take place. (220) Sleep helps to restore both mind and body. The bodys engines are able to slow down and cool off when we sleep, decreasing the metabolic processes, heart rate, respiration, digestion, and body temperature. Sleep can also be a time of increased healing or, in children, a time of accelerated growth. (Abaci, Take Charge of Your5

Chronic Pain: The Latest Research, Cutting-Edge Tools (Globe Pequot Press 2010) p. 241, n. omitted.) Deep sleep coincides with the release of growth hormone in children and young adults. (190) [S]leep seems to be particularly important during periods of brain maturation. (Across species, maturing individuals sleep more than fully mature individuals.) (220) [A]dolescent sleep systems appear to become more vulnerable to stress at a time when social turmoil and difficulties are often increasing. (220) Restricted sleep and interrupted circadian timing, discussed infra, serve as environmental/physiological stressors in humans. (183, 221, Wise, Hopkin, & Garland, Handbook of Aviation Human Factors (CRC Press 2nd ed. 2009) p. 18-3.) Sleep loss means sustaining wakefulness longer, which stresses the body, leading to additional problems. (222) Prenatal development, infancy, childhood and adolescence are times of increased vulnerability to stressors. The presence of stressors during these critical periods can have prolonged effects, such as sustained cacostasis [defective homeostasis, dyshomeostasis, distress] that can last the entire lifetime of an individual. (223) B. Adolescent Circadian Timing All life on earth has evolved under a rhythmically changing cycle of light and darkness, and organisms from single-celled bacteria up to man possess an internal representation of time. These 24 hour cycles, termed circadian rhythms, persist in the absence of external cues, and provide a means of anticipating changes in the environment rather than passively responding to them. In mammals, including man, light provides the critical input to the circadian system, synchronising the body clock to prevailing conditions. (248)---Russell Foster, Ph.D., F.R.S., Chair of Circadian Neuroscience, Oxford University [circadian: circa = about; die = day]. Although sleep/wake patterns have long been known to delay in adolescents, behavioral factors (e.g., jobs, social diversions, scholastic obligations) were assumed to be entirely responsible. (21, 191) Terman and Hocking in 1913, for example, noted a shift from vesperal to matinal sleeping during adolescence, attributing the change to increasing homework. (21) In the 1970s, researchers recognized that sleep patterns change fundamentally at the transition to adolescence. (5) Adolescence commences at pubertys onset; (2) i.e., when children attain Tanner stage 2 (sexual maturation rating). (250, Stang & Story, Adolescent Growth and Development, publish. in, Guidelines for Adolescent Nutrition Services (Stang & Story, edits., Univ. Minn. 2005) p. 1.) The normal age range of pubertal onset is between 8 and 13 years in girls and between 9 years 6 months and 13 years, 6 months in boys. (249) The timing and tempo of puberty vary widely, even among healthy children. (250) Adolescence concludes at about 19.5 years in girls and 20.9 years in boys. (7, 103)

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In 1993, Carskadon and colleagues determined that the circadian system undergoes developmental biological changes when puberty arrives. (1, 191) Other researchers have made similar observations, together providing converg[ing] evidence that the circadian phase undergoes a delay in association with puberty[.] (Carskadon, Maturation of processes regulating sleep in adolescents, publish. in, Sleep in Children: Developmental Changes in Sleep Patterns (Marcus, Carroll, & Donnelly eds., Informa Healthcare, 2nd ed. 2008) p. 100.) Growing evidence supports the conjecture that endogenous circadian period and light sensitivity of the circadian system are altered during puberty in humans and animals. Such changes could explain the development of delayed sleep phase during puberty. (103) Recent studies demonstrate adolescent changes in sleep (delayed sleep phase and disrupted sleep) are evident prior to the bodily changes associated with puberty. (Wolfson & Richards, Young Adolescents: Struggles with Insufficient Sleep, publish. in, Sleep and Development (Oxford Univ. Press., El Sheikh edit. 2011) p. 268, citations omitted.) Young people have special needs during adolescent development that are related directly to their intrinsic sleep cycles. (6) The sleep pressure rate, or homeostatic drivethe biological trigger that causes sleepinessslows down in adolescence. (26, 103) Adolescents develop a resistance to sleep pressure that permits them to stay up later. (103) At the same time, their circadian phase becomes relatively delayed, which provides them with a drive to stay awake later in the evening and to sleep later in the morning. (103) The magnitude of the delay is greater on nonschool days. (21) Additionally, rising time on nonschool days also gets later as adolescence progresses. (21) The preferred sleep onset time for most adolescents is 11 p.m. or later. (2, 7, 8, 9) Bedtime gets later on school and nonschool days with increasing adolescent age. (21, 191) The circadian system and melatonin, a sleep-inducing hormone, direct a sleep cycle in teens which operates from approximately 11 p.m. to 8 a.m. (2, 3, 6, 7, 8, 9) The pubertal stage correlates with the circadian phase marker such that more mature children show a later phase of melatonin secretion offset. (21, Carskadon, Maturation of processes regulating sleep in adolescents, publish. in, Sleep in Children: Developmental Changes in Sleep Patterns (Marcus, Carroll, & Donnelly eds., Informa Healthcare, 2nd ed. 2008) p. 100 [the presence of melatonin may be measured in salivary levels].) Melatonin continues in peak production until 7 a.m., then stops at 8 a.m. (24) In adults, levels peak at 4 a.m. Therefore, waking a teenager at 7 a.m. is equivalent to waking up an adult at 4 a.m. (20, 24) According to Stanford sleep expert Dr. William Dement, adolescents biological rhythms are set in such a way that they really cant wake up earlier. Its like telling a person they have to jump eight feet. They just cant.(184)

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Many parents and teachers become frustrated that adolescents seem to create their own problem of not getting enough sleep by choosing a late bedtime, despite their complaints of sleepiness in the morning. However, there are multiple factors that contribute to later bedtimes, and it is increasingly clear that adolescents stay awake later largely for biological, not social, reasons. As with adults, the physiological factor that most powerfully regulates the timing of waking and sleeping in adolescents is the circadian rhythm, a hard-wired clock in the suprachiasmatic nucleus of the brain. (2) Phase delayed sleep/wake patterns prevail among adolescents globally. (251, 252, 253, 254, 255, 256, 257) [A] delay in the timing of sleep during the second decade of life has been observed in over 16 countries on 6 continents, in cultures ranging from pre-industrial to modern. (103) Forced awakening does not appear to reset the circadian rhythm. (Wahlstrom, Accommodating the Sleep Patterns of Adolescents Within Current Educational Structures: An Uncharted Path, publish. in, Adolescent Sleep Patterns, Biological, Social, and Psychological Influences (Carskadon, edit., Cambridge Univ. Press 2002) p. 174, ns. omitted.) Scientists have repeatedly observed that adhering to Poor Richards judgment Early to bed, early to risemay be difficult in the presence of a biologically driven phase preference. (1, 7, 32) Light/Technology Exposure Nearly all adolescents in the U.S. have at least one electronic item such as a television, computer, telephone, or music device in their bedrooms. (25, 105) The brightness of a television or computer screen may interfere with melatonin release, because release occurs only under dark conditions. (105) In turn, regulation of the sleep-wake cycle may be disturbed. (105) Electronic device multitasking appears to be a good predictor of diminished sleep. (105) Video gaming may be particularly disruptive to adolescent sleep.(108)

As little as five hours exposure to normal levels of indoor lighting, and not just very bright light, can reset the human biological clock, a finding which indicates that many people in industrialized countries may be constantly sleep deprived and in a permanent state of jet lag. (280) A study of Brazilian adolescents living without electricity showed a delay in sleep, however, those living in nearby electrified homes delayed sleep to a greater degree and slept less. (Carskadon, Maturation of processes regulating sleep in adolescents, publish. in, Sleep in Children: Developmental Changes in Sleep Patterns, supra, p. 96.)

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Although light treatments have served to modify circadian timing in some populations, a 2005 study reported early morning light treatments did not change adolescent sleep/wake cycles or improve daytime performance during weekdays. (6) By contrast, carefully controlling light exposure, including wearing eyeshades to exclude evening light, has been successful in modifying adolescent circadian timing. (8) However, this approach may be less than practical for most adolescents. Inadequate exposure to short-wavelength (blue) light further delays the adolescent sleep/wake cycle, pushing back the onset of melatonin by about six minutes for each morning light-deprived day. (281) According to Mariana Figueiro, Ph.D., Assistant Professor and Program Director at Rensselaer Polytechnic Institutes Lighting Research Center, As teenagers spend more time indoors, they miss out on essential morning light needed to stimulate the bodys 24-hour biological system, which regulates the sleep/wake cycle[.] (282) The problem is that todays middle and high schools have rigid schedules requiring teenagers to be in school very early in the morning. These students are likely to miss the morning light because they are often traveling to and arriving at school before the sun is up or as its just rising. This disrupts the connection between daily biological rhythms, called circadian rhythms, and the earths natural 24-hour light/dark cycle, explains Figueiro. (282) In addition, the schools are not likely providing adequate electric light or daylight to stimulate this biological or circadian system, which regulates body temperature, alertness, appetite, hormones and sleep patterns. Our biological system responds to light much differently than our visual system. It is much more sensitive to blue light. Therefore, having enough light in the classroom to read and study does not guarantee that there is sufficient light to stimulate our biological system. (282) The situation in schools can be changed rapidly by the conscious delivery of daylight (e.g., via large windows/skylights), (283) which is saturated with blue light. (282) We hypothesize that if light has an impact on students performance and wellbeing, it is by promoting their circadian entrainment [synchronization] to the solar day, especially in winter months. Those who are not exposed to enough daylight will experience a more pronounced delayed circadian phase, which will result in sleep problems and more severe stress. (284) Figueiro and Professor of Architecture and Cognitive Sciences Mark Rea postulate that those who do not get enough shortwavelength light during the school day will exhibit reduced scholastic performance.(281)

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III.

The Intersection of School Start Times and Adolescent Health/Academic Performance

Our study does confirm that on school days adolescents are obtaining less sleep then they are thought to need, and the factor with the biggest impact is school start times. If sleep loss is associated with impaired learning and health, then these data point to computer use, social activities and especially school start times as the most obvious intervention points. (28)---Kristen Knutson, Ph.D., M.A., Assistant Professor of Medicine, Pulmonary/Critical Care, University of Chicago, Department of Medicine, Diane Lauderdale, Ph.D., M.A., M.A., Professor of Epidemiology, University of Chicago. Most high schools begin during the 7 oclock hour, (12, 21, 22, 23) while melatonin still pressures adolescents to sleep. (3, 24) Schools begin early for administrative and financial reasons, rather than because of any perceived benefits to students. (12, 310) Multi-tiered busing schedules often save school districts money. (12, 310) High school students average two hours less sleep on school nights than on weekends or weekdays during summer. (6, Mindell & Owens, Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems (Lippincott Williams & Wilkins, 2nd ed. 2010) p. 258.) The starting time of school puts limits on the time available for sleep. This is a nonnegotiable limit established largely without concern for sleep. (5) Early high school start time is a significant, externally imposed constraint on teenagers sleep/wake schedules; for most adolescents, waking up to go to school is neither spontaneous nor negotiable. (21) Most teenage students would sleep longer on school days if not for the typical 7:30 a.m. or earlier school start-times. (Rauch, What is Normal Sleep for Children and Adolescents? publish. in, Attention Deficit Disorder: Practical Coping Mechanisms (Fisher, edit., Informa Healthcare, 2nd ed. 2007) p. 175, ns. omitted.) Early school start times contribute substantially to sleep deprivation in teens. (2, 6, 8, [S]chool sleep lag is worse for earlier starting schools. Additional weekend sleep does not alleviate this negative effect. (Wahlstrom, Accommodating the Sleep Patterns of Adolescents Within Current Educational Structures: An Uncharted Path, publish. in, Adolescent Sleep Patterns, Biological, Social, and Psychological Influences (Carskadon, edit., Cambridge Univ. Press 2002) p. 174, ns. omitted.) Weekend oversleep further contributes to circadian disruption and decreased daytime alertness levels. (6)21, 22, 23, 26, 27, 28, 29, 31, 32, 33, 38)

Most districts set the earliest starting time for older adolescents and the latest starting time for younger children. Ironically, the school starting time moves earlier as childrens grade advances. Although school starts earlier, children cannot adjust their bedtime accordingly, and this could result in sleep deprivation. (Cardinali, Chronoeducation: How the Biological Clock Influences the Learning Process, publish. in, The Educated Brain: Essays in Neuroeducation (Battro, Fischer, & Lna, edit., Cambridge Univ. Press 2008) p. 121.) [I]ncreasing societal demands promoted by a10

24/7 culture over the past three decades have contributed to even earlier school start times for both middle and high school students. (2) [T]he widespread practice in U.S. school districts for school buses to run and for the opening bell to ring earlier at high schools than at junior high schools, and earlier in junior high schools than primary schools, may run precisely counter to childrens biological needs. (1) Adolescence is associated with a circadian phase delay with an increasing preference to sleep at later hours; despite this, in most U.S. school districts school days begin progressively earlier as students transition from elementary to middle school and then from middle school to high school. (121) Multiple surveys of high school students conducted in the 1980s and 1990s found that students who start school at 7:30 a.m. or earlier obtain less total sleep on school nights than students at later starting schools. (21) A study published in 1992 found 12th graders beginning school at 7:40 a.m. reported getting less school-night sleep, more sleep problems, and sleeping later on weekends than 12th graders starting school at 8:30 a.m. (34) (Subjective measures of sleep from children and adolescents are correlated with objective measures.) (311, 312) In 1994, a study of 3,120 adolescents attending four Rhode Island high schools with start times ranging from 7:10 a.m.7:30 a.m. found most students were sleep deficient. 87% of the students reported needing more sleep than they were getting. (35, 36) Studies published in 2007, (30) 2009, (28) and 2011 (313) also found that students attending schools with early start times obtained significantly less sleep than students at later starting schools. These outcomes are consistent with the findings of other published studies. (2, 12, 27, 37, 38, 39) An exhaustive search has failed to uncover any contrary research findings. [E]arly school start times, which our results indicate were the main predictor of an earlier wake time among adolescents on school days, conflict with adolescent circadian biology. The fact that these adolescents spent 2 hours less time in bed on school days is consistent with one other study among 60 high school seniors that observed sleep duration reduced by an average of 2 hours on school days. Another study found that students attending schools with later start times (8:37 AM versus 7:15 AM) obtained almost an hour more sleep. [O]ur study does confirm that on school days adolescents are obtaining less sleep then they are thought to need, and the factor with the biggest impact is school start times. If sleep loss is associated with impaired learning and health, then these data point to computer use, social activities and especially school start times as the most obvious intervention points. (28)

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The problem of inadequate sleep affects more segments of our society than adolescents; however, adolescents appear to be particularly vulnerable and face difficult challenges for obtaining sufficient sleep. Even without the pressure of biological changes, if we combine an early school starting timesay 7:30 a.m., which, with a modest commute, makes 6:15 a.m. a viable rising timewith our knowledge that optimal sleep need is 9 hours, we are asking that 16-year-olds go to bed at 9 p.m. Rare is the teenager of the 1990s who will keep such a schedule. School work, sports practices, clubs, volunteer work, and paid employment take precedence. When biological changes are factored in, the ability even to have merely adequate sleep is lost. (5) Some bus riders may need to awaken during the 5 oclock hour. (3, 314) The 2011 National Sleep Foundation poll found 54% of teenagers (13-18 years) awaken between 5 a.m. and 6:30 a.m. on weekdays, with the majority (81%) getting to bed at 10 p.m. or later. (25) Thus, on school days, 6 in 10 obtain fewer than 8 hours of sleep. (25) Studies of middle school students have also found early school start times associated with sleep deficiency and its attendant problems. In addition to the sleep deficit, school records indicated that students at the earlier starting school were tardy four times more frequently, and eighth graders at the earlier starting school obtained significantly worse average grades than the eighth graders at the comparison, later starting school. (30) Even pre-adolescent fifth grade students reported significant sleep deprivation when an extremely early school start time of 7:10 a.m. was imposed. (315) Students attending early starting schools are likely to carry significant chronic sleep debt. (38) Early rise times also interrupt a critical sleep phase. Getting adequate dream (rapid eye movement [REM]) sleep is essential to perceptual, cognitive, and emotional processing. Selective REM sleep deprivation has been demonstrated to cause symptoms of irritability and moodiness, as well as problems with memory. The issue of undersleeping in adolescents takes on added significance when one considers that waking up too early costs the sleeper mostly REM sleep which predominates during the last two to three hours of a nights sleep. (2) In REM sleep, many parts of the brain are as active as at any time when awake. One study found that REM sleep affects learning of certain mental skills. People taught a skill and then deprived of non-REM sleep could recall what they had learned after sleeping, while people deprived of REM sleep could not. (190) Associate Professor of Psychology Avi Sadeh, a leading authority in this field, has concluded that in teens, A loss of one hour of sleep is equivalent to [the loss of] two years of cognitive maturation and development. (139, 316)(189)

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[P]eople who are sleep-deprived are less efficient, thus a cycle develops in which a student takes longer to complete the same amount of work, leading to her staying up later, and starting the vicious cycle all over again. (Mindell & Owens, Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems (Lippincott Williams & Wilkins, 2nd ed. 2010) p. 258.) Researchers have also found a general cloud of negative daily affect that is associated with chronic patterns of inadequate sleep among adolescents.... (118) Dr. Carskadon is persuaded that these early school start times are just abusive. (16) Children may feel adapted to being tired, but performance tests show the opposite. (317, 318) Although conventional wisdom holds that individuals can train themselves to adapt to less sleep, laboratory tests belie this. (319) Chronically sleepdeprived teens often become so used to the feeling of sleepiness that they dont recognize that they are settling for less than they are capable of in creativity, academic performance, and communication both in and out of the classroom. (Rauch, supra, p. 175.) A 2009 study of Chicago public high schools found students beginning morning classes at 8 a.m. show marked deficiencies in performance in first period courses throughout the term. (320) As in other early starting schools, (2, 30, 41) the students were more likely to be absent (about 6 more days per year) in first period relative to other periods. (320, see discussion, n. 570, infra.) [E]arlier start times are associated with significant sleep deprivation, daytime fatigue, irregular sleep schedules, and the tendency to fall asleep at school [] This clash between bodily rhythms and contextual factors can have a wide variety of negative consequences. Insufficient sleep results in an increased risk for school absences because of physical illness, falling asleep in school, oversleeping in the morning, fatigue, and irritability, all of which are detrimental to academic outcomes[.] (23) Economists from Columbia University and the University of Michigan calculate that the earliest school start times are associated with annual reductions in student performance of roughly 0.1 standard deviations for disadvantaged students, equivalent to replacing an average teacher with a teacher at the sixteenth percentile in terms of effectiveness. (49) A 2005 study published in Pediatrics, the official Journal of the American Academy of Pediatrics, concluded, School schedules are forcing [adolescents] to lose sleep and to perform academically when they are at their worst. (6) A. Academic Performance Sleep, in essence, is food for the brain. (4)---James Maas, Ph.D., Retired Professor of Psychology, Stephen H. Weiss Presidential Fellow, Cornell University. Sleep plays an important role in learning and memory, (11, 111, 113, 114, 117) with studies finding an inverse relationship between sleep and academic performance in children, adolescents, and young adults at every educational level. (2, 24, 27, 29, 21, 30, 34, 35, 44, 112, 115, 116, 181) Sleep loss is associated with brief mental lapses in attention during simple tasks that can be13

partially offset by increased effort or motivation. (11, 220) Tiredness and fatigue, however, tend to diminish motivation, particularly for tasks perceived as boring or tedious. (220) Sleep deprivation can sometimes mimic or exacerbate symptoms of ADHD (attention deficit/hyperactivity disorder), including distractibility, impulsivity, and difficulty with effortful control of attention. (220, 11) There is also evidence that sleep deprivation has marked influences on the ability to perform complex tasks or tasks that require attention in two or more areas at the same time. (11, 21, 220) Memory consolidation, long-term recall, and retrieval, particularly of novel material, are all affected by sleep restriction. (182) [I]nstalling new memoriesi.e., learningclearly benefits from, if not depends upon, intervals of normal sleep. (2) Not getting enough sleep may result in problems with attention, memory, decision-making, organization, and creativity, all of which are clearly important for success in school. [] [S]tudies actually show that students who get better grades sleep more, not less. (Mindell & Owens, Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems (Lippincott Williams & Wilkins, 2nd ed. 2010) p. 258, original italics.) Scientists have consistently found a constellation of sleep factorsearlier bedtimes, more total sleep, and later rise timesassociated with superior academic performance and higher grades. (2, 29, 30, 34, 181, see also, discussion n. 345, infra.) A meta-analysis (statistical method combining different study results) of 61 studies found poor sleep quality, insufficient sleep and sleepiness significantly associated with worse school performance among students 8-18 years of age. (340) In 2009, Kyla Wahlstrom, Director of the Center for Applied Research and Educational Improvement (CAREI), noted that in schools which have delayed start times, the academic trend following the change goes exclusively towards higher grades, (45) an assertion which appears supported by the evidence. (13, 30, 34, 35, 41, 44, 139, 316, 341, 342) A 2011 study of Israeli middle school students found significant improvement in mathematics and alphabet attention tasks when classes were delayed by one hour to 8:30 a.m. (13, 343) The study strongly recommends that middle schools should consider delaying the school starting time by at least one hour. Such a change could enhance students cognitive performance by improving their attention level, increasing rate of performance, as well as reducing their mistakes and impulsivity. (13, italics added.) Similarly, when start times were delayed by one hour, to 9:30 a.m., Norwegian 10th graders demonstrated improved performance in reaction time tests (e.g. psychomotor vigilance tasks), proven as valid predictors of performance and levels of fatigue[.] (344) Finley Edwards, Ph.D., compiled test data covering a 10-year period for middle school students in Wake County, North Carolina. (44) Edwards found delaying start times by one hour (from 7:30 a.m.) lead to a 3 percentile point gain in standardized math and reading test scores for the average middle school student in Wake County, North Carolina. (44) The improvement was greatest for the bottom half of the distribution, suggesting that delaying start times may be particularly important for schools14

attempting to reach minimum competency requirements. (44) Edwards also found later start times associated with decreased absences, less time spent watching television and a greater amount of time spent on homework, indicating that these factors may help explain why later starting students have higher test scores. (44) Georgetown University Assistant Professor of Public Policy Peter Hinrichs has found later start times had no effect on ACT college entrance exam testing scores in Kansas or Minnesota. (345) As Hinrichs points out, however, only 59-66% of Minnesota students sat for the ACT test. (345) (The percentage of Kansas test-takers is unstated.) Edwards surmises his results differ from Hinrichs because start times have a greater impact on the bottom half of students. (44) In 2002, echoing the same point, Wahlstrom noted Those students who do take these tests [SAT/ACT] typically tend to be the most academically able, attend classes regularly, and are likely have study habits that supercede any tiredness they experience. As a result, it is difficult to compare their scores with those of their suburban counterparts on nationally normed tests. (37) Until recently, most researchers did not believe a cause and effect relationship between later start times and higher scores had been adequately established. Even so, as Wahlstrom recognized, there is clearly a statistical relationship between these two variables that may be explained by other variables (e.g., less depression, less struggle to stay awake in class) that change when the start time of school is changed. (342, emphasis in original.) One recent study appears to have isolated the effect of later start times on academic performance. Bearing in mind that adolescence lasts until around 19.5 years for women and 20.9 years for men, (7, 103) a four-year study of more than 6,100 first semester United States Air Force Academy freshman published in the American Economic Journal: Economic Policy, found a 50 minute delay in the first class increased grades by 0.15 standard deviations. (24) The researchers, economists from the United States Air Force Academy and the University of California, controlled for potentially confounding factors -- grading structure, class selection and teachers, for example -- to determine the causal effect of start times on academic achievement. (24) We find that when a student is randomly assigned to a first period course starting prior to 8 a.m., they perform significantly worse in all their courses taken on that day compared to students who are not assigned to a first period course. Importantly, we find that this negative effect diminishes the later the school day begins. [] Our findings suggest that pushing back the time at which the school day starts would likely result in significant achievement gains for adolescents. [] Students with a first period class are disadvantaged for two reasons. First, they are in class at a time that their body wants to be asleep, which both makes it difficult to

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learn and fatigues the brain. Second, they may be getting less sleep than their peers who napped during first period. [] Our findings have important implications for education policy; administrators aiming to improve student achievement should consider the potential benefits of delaying school start time. A later start time of 50 minutes in our sample has the equivalent benefit as raising teacher quality by roughly one standard deviation. Hence, later start times may be a cost-effective way to improve student outcomes for adolescents. (24, italics added.) Stanford University economist Eric Hanushek calculates that replacing one average teacher with one above average teacher (one standard deviation above the mean) for a class of 20 willeach yearraise students aggregate earnings by more than $400,000. (346) Economists from Columbia University and the University of Michigan estimate an increase of $17,500 in individual student earnings in present value based upon a one hour delay in morning classes, from roughly 8 a.m. to 9 a.m. (49) Edwards study and the study of Air Force Academy cadets suggest that changing start time policies generates these effects for the entire middle or high school. (49) Professor Maas proposes we reconsider Poor Richards advice. Sleep deficit is hampering high school achievement. Tiredness should not be confused with laziness. All teens should have the right to learn in an optimum environment. Rather than the early to bed... adage, the new adage should be, Wake up later and your grades will be greater. (4) B. Depression, Anxiety, and Fatigue Among adolescents, daily feelings of anxiety, depression, and fatigue are the most consistent psychological outcomes of obtaining less sleep at night. (118)---Andrew Fuligini, Ph.D., Professor of Psychiatry & Biobehavioral Sciences, David Geffen School of Medicine, UCLA, Christina Hardway, Ph.D., Assistant Professor of Psychology, University of Michigan. The prevalence of depression increases with age, especially after the onset of puberty. (380) Excessive irritability, moodiness, sleep and appetite changes may signal a vulnerability to depression. (381) [D]epression is not only a symptom of sleep deprivation but can also be a cause. (381) Scientists refer to this as a bidirectional relationship (Dobson & Dozois, Risk Factors in Depression (Academic Press 2008) p. 109), or bidirectional causal pathway. (23) Adolescents who present with depression display high rates of sleep disturbance and those who present with complaints of poor sleep display high rates of depression. This may create a perpetual cycle, where lack of sleep leads to feelings of fatigue and apathy at school, impaired

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academic and social functioning, reduced levels of motivation, and impaired ability to regulate mood and emotional responses. (119) Depressed children often report disturbed sleep despite normal architecture measured by electroencephalography. (134) Adolescents who are anxious, depressed, or feel less healthy may in fact, need more sleep than those with better psychological functioning. The challenges of getting through an ordinary day may require increased energy for these adolescents. (134) Depressed adolescents frequently have difficulty falling asleep, are unable to get up or refuse to go to school, sleep until late in the day, complain of extreme daytime fatigue, and, over time, shift to increasingly more delayed sleep-wake schedules. (220) Reports of depression have been shown to decline in schools which have delayed start times. (3, 37, 41, 47) Depression is linked to suicidal ideation in teens. (380, 382, 383) C. Suicidal Ideation and Completed Suicide The majority of children who attempt or contemplate suicide are likely to suffer from depression. (380, 382, 383) Sleep loss or disturbances may signal an increased risk of future suicidal action in adolescents. (120, 121, 122, 123, 124) A 2011 study published in the Journal of Psychiatric Research found that children who had trouble sleeping at 12 to 14 years of age were more than twice as likely to have suicidal thoughts at ages 15 to 17. (400, 401) The association between short sleep duration and suicidality has been hypothesized to be due, in part, to the negative effects of insufficient sleep on judgment, concentration, and impulse control. (121) Sleep problems and sleep deficiency have long been associated with suicidal ideation in teens. (52, 53, 400) Suicide is the third leading cause of death among adolescents, in recent years accounting for 10% or more of all teen fatalities. (402, 403) Recent data put the suicide rate in the general population at 2.7%. (404) Poor academic performance is among the risk factors for teen suicidality. (382, 405) As previously noted, sleep deficiency is closely associated with poor academic performance. (2, 27, 29, 30, 34, 35) D. Psychomotor Performance/Automobile Accidents Sleep deprivation, whether from disorder or lifestyle, whether acute or chronic, poses significant cognitive risks in the performance of many ordinary tasks such as driving and operating machinery. (420)---Jeffrey S. Durmer, M.D., Ph.D., Assistant Professor, Department of Neurology, Emory University School of Medicine, David F. Dinges, Ph.D., Professor of Psychology in Psychiatry, Associate Director, Center for Sleep and Circadian Neurobiology, University of Pennsylvania School of Medicine.

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There is increasing evidence correlating early start times with higher crash rates among adolescents. (31, 46, 421, 422) Both motor and mental acuity suffer when we are sleep deprived, which can lead to dangerous human errors and accidents. Studies done on test subjects with occupations associated with sleep deprivationincluding pilots, truck drivers, and medical residentstypically show a greater risk for fatigue-related mistakes and crashes. Accidents related to lost lives and billions of dollars in costs. (Abaci, Take Charge of Your Chronic Pain: The Latest Research, Cutting-Edge Tools (Globe Pequot Press 2010) p. 241, n. omitted.) In 1999, school districts in Lexington, Kentucky delayed start times for high school students county-wide by one hour to 8:30 a.m. (31) Average crash rates for teen drivers in the study county in the 2 years after the change in school start time dropped 16.5%, compared with the 2 years prior to the change, whereas teen crash rates for the rest of the state increased 7.8% over the same time period. (31) The researchers concluded that allowing adolescents to sleep more on school nights by delaying the start of school not only results in them sleeping more, but also may have a measurable positive effect on their driving safety. (31) In reviewing the study, John Cline, Assistant Clinical Professor of Psychiatry at the Yale School of Medicine, commented, Given the danger posed to young people from car accidents this is a strong reason in itself to change school start times. (423) A 2011 study published in the Journal of Clinical Sleep Medicine found that in 2008, the teen crash rate was about 41% higher in Virginia Beach, Virginia, where high school classes began at 7:207:25 a.m., than in adjacent Chesapeake, Virginia, where classes started an hour later at 8:408:45 a.m. (421) Although a cause and effect relationship has not been established, the Virginia study associates early start times with increased teenage car crash rates. (46, 422) We were concerned that Virginia Beach teens might be sleep restricted due to their early rise times and that this could eventuate in an increased crash rate, said lead author Robert Vorona, M.D., Associate Professor of Internal Medicine at Eastern Virginia Medical School in Norfolk, Virginia. (421) Similar results were found for 2007, when the weekday crash rate for Virginia Beach teens (71.2) was 28 percent higher than for Chesapeake teens (55.6). (46) In a secondary analysis that evaluated only the traditional school months of September 2007 through June 2008, the weekday crash rate for teen drivers was 25 percent higher in Virginia Beach (80.0) than in Chesapeake (64.0). (46) The morning peak in crash rates occurred one hour earlier in Virginia Beach than in Chesapeake. (46) The congestion data for Virginia Beach and Chesapeake did not explain the different crash rates. (46, 422) Dr. Vorona contends delaying high school start times may promote driver alertness by reducing the severity of chronic sleep restriction, a common problem during adolescence. (421) We believe that high schools should take a close look at having later start times to align with circadian rhythms in teens and to allow for longer sleep

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times. Too many teens in this country obtain insufficient sleep. A burgeoning literature suggests that this may lead to problematic consequences including mood disorders, academic difficulties and behavioral issues. (421) Harvard Professor of Medicine Stuart Quan concurs: They are additional data suggesting that high school start times should be delayed to increase the amount of sleep that teenagers get during the school week and, hence, reduce the amount of sleep deprivation they incur. (343) Teenagers, especially older teenage boys, are at the highest risk for falling asleep at the wheel. The most common drowsy driving accident involves a single vehicle with a single driver who drives off the road. These accidents happen most often late at night and in the middle of the afternoon. So dont be fooled that just because it is bright daylight, your teen wont fall asleep at the wheel. In addition, all teens who are not getting enough sleep are at risk, especially when a beer or two, marijuana, and relative driving inexperience compound lack of sleep. (Mindell & Owens, Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems (Lippincott Williams & Wilkins, 2nd ed. 2010) p. 258.) Consistent with previous studies, (2) a five year study by the Ohio Department of Transportation released in August of 2011 showed that 7 a.m. is the most dangerous time for teens driving to school. (424) Given that the sleep-inducing hormone, melatonin, pressures adolescents to sleep until approximately 8 a.m., (3, 24) this outcome should not be surprising. Nationally, sleepiness is the leading cause of motor vehicle crashes among drivers 16 to 29 years of age. (21, 46, 425) Psychomotor impairment due to sleep deprivation, as seen on tests like driving performance, can resemble that seen with blood alcohol levels between .05 and .10 percent. (426, 427, 428, Abaci, supra.) Motor vehicle crashes are the leading cause of death for U.S. teens, accounting for more than one in three deaths in this age group. (403, 177) E. Athletic Performance Sleep is a universal recovery strategy that is essential to both physiological adaptation and to the consolidation of skill development[.] (440) Sleep deprivation and sleep disturbance can impair mental and physical function, immune response and other restorative processes important for athletes. (440) Athletes should aim for 10 hours of sleep per night. Adolescent athletes may need more sleep. (440) Just as insufficient sleep is associated with diminished athletic/psychomotor performance, (126, 420, 426, 427, 428) so extra sleep is correlated with improved athletic/psychomotor performance. (125) The benefits of extra sleep for athletes have been established repeatedly. (441, 442, 443, 444, 445) Increased sleep is associated with faster reaction

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times, (141, 446) improved peripheral vision, (447) and peak athletic performance. (448) Sleepiness, by contrast, can increase the risk of sports injuries in teens. (449) Dr. Phil Eichling, a sleep medicine specialist, notes that peripheral vision can be affected by loss of sleep resulting in slow eye movement. (447) Decreased peripheral vision is a huge competitive disadvantage for athletes. (447) Sleep duration may be an important consideration for an athletes daily training regimen, according to Dr. Cheri Mah of the Stanford Sleep Disorders Clinic and Research Laboratory. Furthermore, sleep extension also may contribute to minimizing the effects of accumulated sleep deprivation and thus could be a beneficial strategy for optimal performance. (450) Dr. Mahs 2010 study of college athletes found most entered training with sleep deficits. The athletes were encouraged to press for extra sleep, up to 10 hours nightly. After several weeks of consistent additional sleep, athletic performance began to improve. (450, 451) While most athletes and coaching staff may believe that sleep is an important contributing factor in sports, many do not realize that optimal or peak performance can only occur when an athletes sleep and sleep habits are optimal. (448, 452) F. Excessive Weight Gain A study published in the September 2010 issue of the journal Sleep found that teenagers who slept less than eight hours per weeknight ate more fatty foods and snacks than adolescents who slept eight hours or more. (470) For each one-hour increase in sleep duration, the odds of consuming a high amount of calories from snacks decreased by an average of 21 percent. (129, 470) A significantly greater proportion of teens who slept less than eight hours per weeknight consumed food in the early morning between 5 a.m. and 7 a.m. (129, 470) According to Harvards Dr. Susan Redline, Altered timing of eating in shorter sleepers also may be a metabolic stress that contributes to metabolic dysfunction. (129, 470) Obviously, being awake for longer hours means more opportunities to eat. Weight gain may be promoted by eating at a time when circadian rhythm dictates sleep. (471) A 2010 CDC study published in the Journal of the American Medical Association reports that the rate of obesity in U.S. adolescents between the ages of 12 and 19 years was 18.1 percent in 2007-2008. (472) The authors noted that the prevalence of high body mass index in childhood has remained steady for 10 years and has not declined despite coordinated prevention efforts. (472) Overweight children and adolescents tend to have reduced REM sleep. (128) Although a recent study suggests otherwise, (473) Dr. Redline and other researchers

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surmise sleep loss may be the missing link (129) in understanding why diet and exercise obesity interventions fail. (127, 130, 474, 475) G. Risk-Taking & Delinquent Behavior Risk-taking is a complex phenomenon, and adolescents seem to be a particularly vulnerable population. (131)--- Erin M. OBrien, Ph.D., Instructor in Psychiatry and Human Behavior, The Warren Alpert Medical School, Brown University, Jodi Mindell, Ph.D., Professor of Psychology, Director, Graduate Program, St. Josephs University, Associate Director, Sleep Center, Childrens Hospital of Philadelphia. In ruling the Eighth Amendment (barring cruel and unusual punishment) prohibits imposing the death penalty for juvenile offenders, the United States Supreme Court noted differences between juvenile and adult offenders. Writing for the Courts majority, Justice Kennedy observed, First, as any parent knows and as the scientific and sociological studies respondent and his amici cite tend to confirm, [a] lack of maturity and an underdeveloped sense of responsibility are found in youth more often than in adults and are more understandable among the young. These qualities often result in impetuous and ill-considered actions and decisions. It has been noted that adolescents are overrepresented statistically in virtually every category of reckless behavior. In recognition of the comparative immaturity and irresponsibility of juveniles, almost every State prohibits those under 18 years of age from voting, serving on juries, or marrying without parental consent. [] The second area of difference is that juveniles are more vulnerable or susceptible to negative influences and outside pressures, including peer pressure. (`[Y]outh is more than a chronological fact. It is a time and condition of life when a person may be most susceptible to influence and to psychological damage). (490) The adolescent qualities referenced by Justice Kennedypsychological vulnerability, impulsivity, immature judgment, susceptibility to negative influence and peer pressuretend to be exacerbated by restricted sleep. (52, 53, 121, 131, 132, 134) Adolescents inability to control emotional responses when sleep deprived could influence aggression, sexual behavior, the use of alcohol and drugs, and risky driving. (21) Teenagers who are sleep deprived are often more impulsive and more likely to engage in risk-taking behaviors, such as drinking, driving fast, and engaging in other dangerous activities. (Mindell & Owens, Clinical Guide to Pediatric Sleep: Diagnosis and Management of Sleep Problems (Lippincott Williams & Wilkins, 2nd ed. 2010) p. 258.) Despite the robust health typical of adolescents, death rates soar at this age largely because of misfortunes associated with elevated risk-taking behaviors, including use of alcohol and other drugs that may further increase the incidence of risky21

behaviors. Adolescence may be a vulnerable period not only because of the high prevalence of risk-taking, but also because of the potential lasting consequences of perturbations to the brain as it is sculpted during this time. For instance, brain regions undergoing particularly marked remodeling during adolescence (e.g., PFC, amygdala, nucleus accumbens) are among those that are most sensitive to alcohol and other drugs of abuse. (Coch, Fischer, & Dawson, Human Behavior, Learning, and the Developing Brain: Typical Development (Informa Healthcare 2010) p. 383, citations omitted.) One unintended consequence of the earlier school schedule is the amount of unstructured time some teens are faced with after school in the afternoons. This selfcare time lends itself to greater risk taking, and has been correlated with increased substance use and depressed mood. Indeed, juvenile crimes are four times more likely to occur in the hours after school than at other times during the day or night. (2, 310) A study published last year in the Journal of Youth and Adolescence found that teenagers sleeping seven or fewer hours per night had a significantly higher rate of property crimes such as vandalism, shoplifting, and breaking and entering than their peers who had 8-10 hours of sleep. (133) Teenagers sleeping five or fewer hours per night had a significantly higher rate of violent crimes such as being involved in a physical fight or threatening someone with a weapon than those teenagers who had slept 8-10 hours. (133) The researchers note, Our analysis provides preliminary evidence that sleepdeprived adolescents participate in a greater volume of both violent and property crime.... Further, our results indicate that every little bit of sleep may make a difference. That is, sleeping 1 (hour) less (i.e., 7 hours) than the recommended range increased the likelihood of property delinquency, and this risk increased for each hour of sleep missed. (133) In a 2005 study of 388 Philadelphia high school students, 67% of participants indicated that they thought they obtained too little sleep. (131) Researchers found students reporting more sleep problems were also more likely to report that they were experiencing behavior problems and substance use. (131) Students who obtained the least amount of sleep on school nights reported greater alcohol usage than those students who obtained the most sleep on school nights, and those students with the biggest difference between their school-night and weekend-night bedtimes reported higher levels of risk-taking behavior and lower academic performance. (131) Overall, the results of this study support the expectation that inadequate sleep and increased sleep problems have negative effects on adolescents daytime functioning, including poorer academic performance, increased daytime sleepiness, negative moods, behavior problems, and increased risk-taking. (131)

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A 2011 CDC study of 12,154 high school students also found an association between diminished sleep and increased likelihood of health-risk behaviors, including use of cigarettes, alcohol, or marijuana, sexual activity, and serious consideration of attempting suicide. (53) These outcomes appear to be universal. A survey of 6,632 students from 349 secondary schools across Italy found an association between increased complaints of daytime sleepiness and poor academic achievement, greater use of caffeine, alcohol, and tobacco, sleep problems, evening phase preference, anxiety, and depressive mood. (Gianotti & Cortesi, Sleep Patterns and Daytime Function in Adolescents: An Epidemiological Survey of an Italian High School Student Sample, publish. in, Adolescent Sleep Patterns: Biological, Social, and Psychological Influences, (Carskadon, edit., Cambridge Univ. Press 2002) pp. 132-147.) Lela McKnight-Eily, Ph.D., lead author of the recent CDC study, recently commented, consideration of delayed school start times may hold promise as one effective step in a comprehensive approach to address this problem. (52) Stimulant Use Young people are increasingly using caffeine to compensate for chronic inadequate sleep. (106, 491) Ironically, falling asleep in school is associated with high caffeine consumption. (105) Caffeine, a methylxanthine and adenosine receptor antagonist, can be considered the most commonly consumed psychoactive substance worldwide. (105) Of the 5,448 US caffeine overdoses reported in 2007, 46% occurred in those younger than 19 years. (212) Currently, the U.S. does not regulate the amount of caffeine in energy drinks. (492) Energy drinks are classified as dietary supplements rather than sodas and are not limited by the same caffeine restrictions that are applied to soft drinks. (492) The FDA limits regular soft drinks to a maximum of 71 milligrams of caffeine per 12 ounce can, however, these limits do not apply to most energy drinks. (492) According to self-report surveys, energy drinks are consumed by 30% to 50% of adolescents and young adults. (492) Reports indicate that some high school students drink as many as five cans of energy drinks a day to combat sleep loss. (29) Frequently containing high and unregulated amounts of caffeine, these drinks have been reported in association with serious adverse effects, especially in children, adolescents, and young adults with seizures, diabetes, cardiac abnormalities, or mood and behavioral disorders or those who take certain medications. (492) Clusters of Sleep/Drug Use Behavior Researchers from Harvard and the University of California mapped the social networks of 8,349 adolescents in order to study how sleep behavior spreads, how drug use behavior spreads, and how a friends sleep behavior influences ones own drug use. (132) Their study found clusters of poor sleep behavior and drug use that extend up to four degrees of separation (to ones friends friends friends friends) in the social

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network. [I]f a friend sleeps