Child and Adolescent Sleep Patterns and Early School Start Times: Recognizing the Role of the Pediatric Nurse

Abstract

THE NEUROPHYSIOLOGICAL PROCESS of sleep produces developmental variations in infants, children, and adolescents, which affect sleep times and rhythms (Czeisler et al., 2012Czeisler C.A. Winkelman J.W. Richardson G.S. Chapter 27. Sleep disorders.in: Longo D.L. Fauci A.S. Kasper D.L. Hauser S.L. Jameson J. Loscalzo J. Harrison's Principles of Internal Medicine. 18th ed. 2012Google Scholar, Dijk et al., 2000Dijk D.J. Duffy J.F. Czeisler C.A. Contribution of circadian physiology and sleep homeostasis to age-related changes in human sleep.Chronobiology International. 2000; 17: 285-311Crossref PubMed Scopus (265) Google Scholar, Ferber, 2006Ferber R. Solve your child's sleep problems.2nd ed. Fireside, New York, NY2006Google Scholar, Ohayon et al., 2004Ohayon M.M. Carskadon M.A. Guilleminault C. Vitiello M.V. Meta-analysis of quantitative sleep parameters from childhood to old age in healthy individuals: Developing normative sleep values across the human lifespan.Sleep. 2004; 27: 1255-1273Crossref PubMed Scopus (1971) Google Scholar, Ropper et al., 2014Ropper A.H. Samuels M.A. Klein J.P. Chapter 19. Sleep and its abnormalities.in: Ropper A.H. Samuels M.A. Klein J.P. Adams & Victor's Principles of Neurology. 10th ed. 2014Google Scholar). For example, in adolescents, sleep requirements do not change but their biologic clock and related sleep patterns shift (Carskadon et al., 2004Carskadon M.A. Acebo C. Jenni O.G. Regulation of adolescent sleep: Implications for behavior.Annals of the New York Academy of Sciences. 2004; 1021: 276-291https://doi.org/10.1196/annals.1308.032Crossref PubMed Scopus (535) Google Scholar). EEG markers show common changes in sleep timing manifested in their preferred later bedtimes and difficulty waking up in the morning during and after puberty (Carskadon, Acebo, & Jenni). These physiological markers are in sharp contrast to findings of typical adolescent sleep, showing a deficiency in hours of sleep, particularly on school nights (National Sleep Foundation, 2014National Sleep Foundation Sleep in the modern family.Sleep in America Poll. 2014Google Scholar). There are multiple factors in addition to quantity of time that contribute to optimal sleep in children and adolescents. Some of these factors include use of personal electronic devices at bedtime, parental supervision, and school schedules (Boergers et al., 2014Boergers J. Gable C.J. Owens J.A. Later school start time is associated with improved sleep and daytime functioning in adolescents.Journal of Developmental & Behavioral Pediatrics. 2014; 35: 11-17https://doi.org/10.1097/dbp.0000000000000018Crossref PubMed Scopus (0) Google Scholar, National Sleep Foundation, 2014National Sleep Foundation Sleep in the modern family.Sleep in America Poll. 2014Google Scholar, Short et al., 2011Short M.A. Gradisar M. Wright H. Lack L.C. Dohnt H. Carskadon M.A. Time for bed: Parent-set bedtimes associated with improved sleep and daytime functioning in adolescents.Sleep. 2011; 34: 797-800https://doi.org/10.5665/sleep.1052Crossref PubMed Google Scholar). Evidence from parent/guardian-enforced bedtimes and delayed school start times has demonstrated longer sleep duration and improved daytime function (Boergers et al., 2014Boergers J. Gable C.J. Owens J.A. Later school start time is associated with improved sleep and daytime functioning in adolescents.Journal of Developmental & Behavioral Pediatrics. 2014; 35: 11-17https://doi.org/10.1097/dbp.0000000000000018Crossref PubMed Scopus (0) Google Scholar, Short et al., 2011Short M.A. Gradisar M. Wright H. Lack L.C. Dohnt H. Carskadon M.A. Time for bed: Parent-set bedtimes associated with improved sleep and daytime functioning in adolescents.Sleep. 2011; 34: 797-800https://doi.org/10.5665/sleep.1052Crossref PubMed Google Scholar). Another consideration is the quality of sleep. Irregular sleep/wake patterns in adolescents have been correlated with adverse academic, psychophysiological, and safety conditions (American Academy of Pediatrics et al., 2014American Academy of Pediatrics Adolescent Sleep Working Group Committee on adolescence and council on school health School start times for adolescents.Pediatrics. 2014; https://doi.org/10.1542/peds.2014-1697Crossref Scopus (246) Google Scholar). The focus of the Society of Pediatric Nurses (SPN) on advocating for adolescent sleep mirrors that of other health organizations. For example, the American Academy of Pediatrics et al., 2014American Academy of Pediatrics Adolescent Sleep Working Group Committee on adolescence and council on school health School start times for adolescents.Pediatrics. 2014; https://doi.org/10.1542/peds.2014-1697Crossref Scopus (246) Google Scholar recently published a review of evidence related to the effects of short sleep duration on adolescent health, highlighting evidence for metabolic dysregulation, obesity, anxiety, and depressive symptoms associated with short sleep duration (Alfano et al., 2009Alfano C.A. Zakem A.H. Costa N.M. Taylor L.K. Weems C.F. Sleep and their relation to cognitive factors, anxiety, and depressive symptoms in problems children and adolescents.Depression and Anxiety. 2009; 26: 503-512https://doi.org/10.1002/da.20443Crossref PubMed Scopus (190) Google Scholar, Verhulst et al., 2008Verhulst S.L. Schrauwen N. Haentjens D. Rooman R.P. Van Gaal L. De Backer W.A. et al.Sleep duration and metabolic dysregulation in overweight children and adolescents.Archives of Diseases in Children. 2008; 93: 89-90https://doi.org/10.1136/adc.2007.124768Crossref PubMed Scopus (21) Google Scholar). Based on this body of evidence, the AAP developed a policy statement supporting the role of health professionals in education of parents, teachers, and students related to improving sleep and urging schools to adopt delayed school start times (American Academy of Pediatrics et al., 2014American Academy of Pediatrics Adolescent Sleep Working Group Committee on adolescence and council on school health School start times for adolescents.Pediatrics. 2014; https://doi.org/10.1542/peds.2014-1697Crossref Scopus (246) Google Scholar). In addition, other organizations invested in the health and well being of society have made sleep-related research findings available to healthcare providers, civic and school leaders, and those engaged in the development of public policy. The National Sleep Foundation, 2014National Sleep Foundation Sleep in the modern family.Sleep in America Poll. 2014Google Scholar has investigated teen sleep habits and public awareness of the unique requirement for sleep that exists in adolescents. It has been active in supporting legislation related to delayed school start times (National Sleep Foundation, 2014National Sleep Foundation Sleep in the modern family.Sleep in America Poll. 2014Google Scholar). Start School Later, Inc. is a national, non-profit organization with local chapters dedicated to the promotion of healthy, safe, and equitable school hours (Start School Later, Inc, 2014Start School Later, Inc www.startschoollater.netDate: 2014Google Scholar). Their Website provides updates pertaining to current legislation and public policy related to school start times and hours, in addition to providing factual information on the role of sleep in child health to disabuse many of the circulating myths related to pediatric sleep needs. The current interest in the plight of sleep deprivation in the nation's youth population coincides with the vision of SPN to be a resource for nurses caring for children and families. Therefore, in 2013 SPN began work on developing a resource related to the promotion of adequate sleep in middle school and high school students. At the same time representatives from Start School Later, Inc. were looking to partner with national pediatric nursing-led organizations to support an initiative to promote adequate sleep for adolescents. The two organizations agreed to support each other's plan to promote later start times for middle and high school students. The SPN's Child Advocacy Committee was asked to consider publishing a position statement in support of the later start time. During the next year, the Child Advocacy Committee researched potential resources including reaching out to the American Academy of Pediatrics (AAP) with which to collaborate on initiatives related to school start times currently in progress. The Child Advocacy Committee made initial contact with the National Association of School Nurses (NASN) in early 2014 regarding the formation of a partnership to research and develop a position statement related to pediatric sleep and the current early start times for most schools. Following this, NASN's Position Document Review Committee determined a full review of school start times was needed. By mid-2014, NASN completed a literature review related to school start times and determined that NASN was ready to move forward and collaborate with SPN to create a joint position document. A collaborative task force was organized composed of members from SPN's Child Advocacy Committee, and NASN's Executive and Research Advisory Committees. As there were many factors that promote or impede sleep in children of all ages, it was determined that the group should concentrate on how growth and development in adolescence is impacted specifically by sleep behaviors and how early start school times can have a negative effect on the adolescent's overall well-being. For the remainder of the year, the task force worked on drafting a joint consensus statement. Final approval for the Early School Start Times Joint Consensus Statement was received by both SPN and NASN in early 2015. The SPN/NASN joint consensus statement is published on the respective Websites. It serves as a first-line resource for nurses seeking data for evidence-based practice. In addition the AAP policy, published on the AAP Website, provides teaching points for caregivers and professionals in the community, school, and health care environment, with a focus on the primary care provider role (American Academy of Pediatrics et al., 2014American Academy of Pediatrics Adolescent Sleep Working Group Committee on adolescence and council on school health School start times for adolescents.Pediatrics. 2014; https://doi.org/10.1542/peds.2014-1697Crossref Scopus (246) Google Scholar). The following SPN/NASN consensus statement fills an information gap concerning process of growth and development and recommendations related to adolescent sleep and school start times for pediatric nursing professionals. Optimal sleep during growth and development is critical for the health, safety and academic success of our nation's youth. Over half of high school youth and near one third in middle school report 7 hours or less sleep on school nights (National Sleep Foundation, 2014National Sleep Foundation Sleep in the modern family.Sleep in America Poll. 2014Google Scholar). These reports are in sharp contrast to recommended adolescent (age 12–17) sleep requirements of approximately 9 to 10 hours (Carskadon, 2011Carskadon M.A. Sleep in adolescents: The perfect storm.Pediatric Clinics of North America. 2011; 58: 637-647https://doi.org/10.1016/j.pcl.2011.03.003Abstract Full Text Full Text PDF PubMed Scopus (494) Google Scholar). The registered professional school nurse (hereinafter referred to as school nurse) is in a pivotal position to collaborate with students, families, teachers, pediatric nurses, school administration officials, and other health care professionals to address factors contributing to insufficient sleep. A significant modifiable factor contributing to insufficient sleep during adolescence is early school start times during middle school and high school. The National Association of School Nurses (NASN) and the Society of Pediatric Nurses (SPN) support delaying school start times for middle school and high school students as proposed in the policy statement on School Start Times for Adolescents by the American Academy of Pediatrics (American Academy of Pediatrics et al., 2014American Academy of Pediatrics Adolescent Sleep Working Group Committee on adolescence and council on school health School start times for adolescents.Pediatrics. 2014; https://doi.org/10.1542/peds.2014-1697Crossref Scopus (246) Google Scholar). This recommendation is based upon the following key factors in adolescent sleep:•Adolescents require approximately 9–10 hours of sleep nightly (Carskadon, 2011Carskadon M.A. Sleep in adolescents: The perfect storm.Pediatric Clinics of North America. 2011; 58: 637-647https://doi.org/10.1016/j.pcl.2011.03.003Abstract Full Text Full Text PDF PubMed Scopus (494) Google Scholar).•Developmental and physiological changes in adolescent sleep contribute to shifts in nighttime sleep times and later bedtimes, but not necessarily a decrease in sleep requirement (Carskadon, 2011Carskadon M.A. Sleep in adolescents: The perfect storm.Pediatric Clinics of North America. 2011; 58: 637-647https://doi.org/10.1016/j.pcl.2011.03.003Abstract Full Text Full Text PDF PubMed Scopus (494) Google Scholar).•Home electronic media use by adolescents before bedtime affect sleep quality (National Sleep Foundation, 2014National Sleep Foundation Sleep in the modern family.Sleep in America Poll. 2014Google Scholar).•Parents/Guardians are unaware of adolescent sleep needs and/or the sleep duration of their adolescents (American Academy of Pediatrics et al., 2014American Academy of Pediatrics Adolescent Sleep Working Group Committee on adolescence and council on school health School start times for adolescents.Pediatrics. 2014; https://doi.org/10.1542/peds.2014-1697Crossref Scopus (246) Google Scholar).•Parent/Guardian-enforced bedtimes throughout adolescence are associated with longer sleep duration (Short et al., 2011Short M.A. Gradisar M. Wright H. Lack L.C. Dohnt H. Carskadon M.A. Time for bed: Parent-set bedtimes associated with improved sleep and daytime functioning in adolescents.Sleep. 2011; 34: 797-800https://doi.org/10.5665/sleep.1052Crossref PubMed Google Scholar).•Delaying school start times for adolescents to no earlier than 8:25 am is associated with longer sleep duration on school nights (Boergers et al., 2014Boergers J. Gable C.J. Owens J.A. Later school start time is associated with improved sleep and daytime functioning in adolescents.Journal of Developmental & Behavioral Pediatrics. 2014; 35: 11-17https://doi.org/10.1097/dbp.0000000000000018Crossref PubMed Scopus (0) Google Scholar).•Delay of school start times is associated with improved mood and reduced daytime sleepiness (Boergers et al., 2014Boergers J. Gable C.J. Owens J.A. Later school start time is associated with improved sleep and daytime functioning in adolescents.Journal of Developmental & Behavioral Pediatrics. 2014; 35: 11-17https://doi.org/10.1097/dbp.0000000000000018Crossref PubMed Scopus (0) Google Scholar).•Insufficient sleep and irregular sleep/wake patterns are associated with an increased risk for daytime sleepiness, academic and emotional difficulties, safety hazards, and cardio-metabolic disease (American Academy of Pediatrics et al., 2014American Academy of Pediatrics Adolescent Sleep Working Group Committee on adolescence and council on school health School start times for adolescents.Pediatrics. 2014; https://doi.org/10.1542/peds.2014-1697Crossref Scopus (246) Google Scholar). The need for sleep is a biological necessity for all mammals, and studies have shown that the absence of sleep results in impairment of functional ability (Iber, 2013Iber C. Sleep & biology of the human brain.CARE! The national teens and sleep conference. 2013Google Scholar). During the four stages of sleep—REM, N1, N2, and N3—task learning is refined through the enhancement and pruning of synaptic connections. Each sleep stage has a responsibility for temporarily storing, evaluating, discarding “nonsense” information and preserving new and valued knowledge (Iber, 2013Iber C. Sleep & biology of the human brain.CARE! The national teens and sleep conference. 2013Google Scholar). During adolescence, the secretion of the melatonin hormone begins later in the day resulting in a corresponding delay in the desire to sleep (Carskadon, 2013Carskadon M.A. The biology of adolescent sleep.CARE! The national teens and sleep conference. 2013Google Scholar). The postponement of this biological event is further delayed if the adolescent is not in a dimly lit environment—often the case if there is homework to finish. However, although staying awake longer is easier for the adolescent, the desire to sleep longer is unavoidable. This becomes problematic when the total amount of sleep is reduced, as is often the case during the school year. In addition, studies have shown that children and adolescents from low income or racial and ethnic minorities are at a greater risk for sleep disorders due to overcrowding, excessive noise, and concerns for their own or their family safety (Owens, 2014Owens J. Insufficient sleep in adolescents and young adults: An update on causes and consequences.Pediatrics. 2014; 134: 921-932https://doi.org/10.1542/peds.2014-1696Crossref PubMed Scopus (683) Google Scholar). In Healthy People 2020, 2014Healthy People 2020 Sleep health. 2020 Topics and objectives.http://www.healthypeople.gov/2020/topics-objectives/topic/sleep-health?topicid=38Date: 2014Google Scholar, a new core indicator has been developed entitled Sleep Health which calls for a reduction in•Adolescent sleep loss;•Unhealthy sleep behaviors (irregular sleep/wake patterns, overuse of electronic media in the bedroom, and the consumption of excessive caffeine); and•The potential consequences of inadequate sleep (depression and suicidal ideation, obesity, auto accidents attributed to drowsiness, and poor academic performance) (Owens, 2014Owens J. Insufficient sleep in adolescents and young adults: An update on causes and consequences.Pediatrics. 2014; 134: 921-932https://doi.org/10.1542/peds.2014-1696Crossref PubMed Scopus (683) Google Scholar). NASN and SPN highlight contributing—and modifiable—factor to promoting an increase in sleep obtained by teenagers is to delay the start of school day for middle and high school students. NASN and SPN acknowledge the challenges of alterations in after-school sports and activities, along with adjustments to parental/guardian schedules and other modifiable factors such as the need for families to:•Self-regulate sleep habits;•Set bedtime limits;•Set limits on social networking; and•Discuss the use of electronic media in the bedroom. SPN and NASN stand ready to collaborate with administrators, teachers, parents, school boards and communities to address this public health issue by:•Working with parents to understand developmental changes in sleep/wake patterns during adolescence.•Educating parents on the importance of setting bedtime limits.•Identifying adolescents at risk.•Working with teachers and parents to monitor academic course loads and extracurricular activities.•Identifying strategies to promote optimal sleep.•Limiting the use of caffeine and other stimulants.•Limiting the use of electronic media and social networking. Adolescence is a time when sleep patterns change and biological clocks alter, often leading to poor quality and insufficient sleep. Their ability to concentrate, problem-solve and assimilate new information is impaired. SPN and NASN encourage all parties involved to consider implementing later school start times for teens. Suggested citation: National Association of School Nurses and Society of Pediatric Nurses. (2014). Consensus Statement: Early school start times. Silver Spring, MD: Author. All consensus statements from the National Association of School Nurses will automatically expire 1 year after publication unless renewed and recommended for position statement development. Society of Pediatric Nurses 330 N. Wabash Avenue, Suite 2000 Chicago, IL 60611 1-312-321-5154 www.pedsnurses.org National Association of School Nurses 8484 Georgia Avenue, Suite 420 Silver Spring, MD 20910 1-240-821-1130 www.nasn.org