John Garcia, MD Diplomate, American Board of Sleep Medicine

1. Improved Student Outcomes with Later High School Start Time John Garcia, MD Diplomate, American Board of Sleep Medicine Diplomate, American Board of Pediatrics

2. Disclosure Information I have no financial relationships to disclose. No Conflicts of Interest No Corporate Affiliations No Speakers Bureaus I will not discuss off label use and/or investigational use in my presentation.

3. 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.

4. Puberty and Melatonin Onset Phase: Hormonal Signal of Nighttime 11pm 10pm 9pm 8pm 7pm Carskadon et al. NYAS, 2004

5. Homeostatic drive lessens in adol.

6. 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

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

8. Carskadon et al. Sleep, 1998

9. 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

10. Hours AGE

11. sleep debt accumulates and is often underestimated Subjective Sleepiness Neurobehavioral deficit While neurobehavioral deficit in increasing, subjective sleepiness may plateau Cumulative sleep loss SLEEP 2003;2:117-126

12. Carskadon, Pediatr Clin North Am, 2011

14. 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.

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

18. Safety: car crashes are related to school start time

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

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

35. Pediatric Sleep Doctor Working with Parents and Schools John Garcia, MD

36. 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.

37. 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.

38. 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.

39. 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.

40. 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.

41. 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

42. 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.

44. 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.

45. 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.

46. 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.

47. 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.