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Adolescent sleep health and school start times: Setting the research agenda for California and beyond: A research summit summary
Abstract
In fall 2019, California passed and signed into law SB328, the first US statewide legislation explicitly designed to protect adolescent sleep health by requiring most California public school districts to start no earlier than 8:00 AM for middle schools and 8:30 AM for high schools. Recognizing the unique opportunity presented by the bill's 3-year implementation period, a group of experts in adolescent sleep and school start times held a virtual summit on January 22-23, 2021 to (1) summarize the research on adolescent sleep and school start time change; (2) develop recommendations for relevant, refined, and innovative research areas and research questions; (3) provide input regarding research design, methodology, and implementation; and (4) offer a forum for networking, exchanging ideas, and establishing interdisciplinary research collaborations. Participants represented a multidisciplinary range of academic backgrounds including sleep and circadian biology, neuroscience, education, medicine, public health, mental health, safety, public policy, economics, implementation science, criminology, diversity studies, and science communication. This paper summarizes summit presentations regarding current knowledge on adolescent sleep health and school start times and key research recommendations from small group workshops on topics including research design and tools, methodological issues, sleep health disparities, logistical challenges in conducting school-based research, public-health impact, and novel and expanded approaches to research.
... Relative to their peers, some adolescents are "morning larks" (or simply "Larks") who prefer earlier bedtimes and wake times, while others are "night owls" (or "Owls") who favor later schedules. In contrast to this variability, one relative constant in the US and many other developed countries is that schools for adolescents start as early as or earlier than those for younger children [4][5][6][7][8]. This causes many adolescents, especially Owls, to sleep far less than the recommended 8-10 h on school nights [5,6,8]. ...
... In contrast to this variability, one relative constant in the US and many other developed countries is that schools for adolescents start as early as or earlier than those for younger children [4][5][6][7][8]. This causes many adolescents, especially Owls, to sleep far less than the recommended 8-10 h on school nights [5,6,8]. ...
... This has led to efforts to alleviate sleep restriction. While advocacy for later school start times has had some impact [6], the practical reality for many adolescents is that-because they must awaken early for school-the only way to achieve adequate sleep is to go to bed early. ...
Despite extensive research on the effects of sleep restriction on adolescent health, the field lacks experimental methods to study the health effects of mistimed sleep, which is also common among adolescents. This paper describes a novel 3-week experimental protocol that was designed to compare sleep restriction, like what many adolescents experience on school nights, against sleep that meets the recommended duration but is timed to be relatively aligned or misaligned with their circadian phase. Healthy 14–18-year-olds, classified as early (“Lark”) and late (“Owl”) chronotypes, entered a six-night chronotype-aligned stabilization condition, followed by five nights of sleep restriction, a return to the stabilization schedule, and five nights of healthy sleep duration (HS). During HS, participants were randomly assigned to early-to-bed versus late-to-rise arms, intended to align with or misalign with their circadian phase. Actigraphy monitored sleep, and weekly dim-light melatonin onset (DLMO) assessed circadian phase. Analyses confirmed that the protocol met five key validation metrics related to differential attrition, sleep timing, circadian phase, and experimental induction of HS that is timed to be relatively aligned vs. misaligned with circadian phase. This protocol appears useful for future research into how misaligned sleep patterns, which occur regularly for many adolescents, may impact health.
... Groups such as the Start School Later movement have pushed to alter school schedules for teens. In the US, California recently became the largest jurisdiction to enact legislation demanding a later (8:30 a.m. at earliest) start time for secondary schools (8). The impact of this change for both teen sleep and its functions remains to be seen. ...
... Compared to when adolescents were allotted nine hours, one night of four hours of sleep did not signifcantly decrease memory recall, suggesting that memory consolidation at this age may be robust, at least in the short term, to partial sleep restriction. In another study, Voderholzer et al. (10) restricted 14-to 16-year-olds across four nights under one of fve protocols (9,8,7,6 or 5 hours of time in bed (TIB)). Before restriction, all had a ninehour sleep opportunity and engaged in two memory tasks (word pairs and procedural learning), with recall assessed twice: after two nights of post-restriction recovery sleep and one month later. ...
... In response to our knowledge of the physiological and social changes compelling adolescents to stay up later in the evenings, some US districts have implemented delayed school start times, with California enacting the frst state-wide law requiring high schools to start no earlier than 8:30 a.m. (8). Both school-wide and multisite studies investigating the efects of such policies have reported promising results, with later start times associated with increases in adolescent school attendance (50), longer sleep (51, 52), higher grades (53) and better mental health (44,50,53) across both suburban and urban school districts. ...
... However, these findings should be considered within the context of the shorter sleep duration previously reported with unhealthy, early start times. 1,46 While districts work to recover achievement, adolescents are struggling not only from learning loss but a sense of lost community and higher rates of depression and anxiety. 40,41,43 Simultaneously, many parents are taking advantage of new options including permanent asynchronous learning. ...
... This work joins a broader literature on sleep and academic success, supporting policies for later, healthy, and developmentally appropriate school start times. 39,46 ...
... Deception in relation to evidence can also lead to charges of contempt of court. However, the potential effectiveness of these tools is limited, as they require the detection of false evidence, and also as their operation is subject to judicial discretion [20,21]. Refusal of the courts to admit the tainted evidence for determination is the most they can do to counter that problem. ...
Deception in legal proceedings encompasses a spectrum of unethical practices, including false representation, bribery, perjury, and manipulation of evidence. These practices undermine the integrity of the legal system, erode public trust, and distort justice. This paper examines the ethical implications of deception in the legal profession, emphasizing the duty of candor and honesty as foundational to justice. It explores the historical and contemporary prevalence of deceptive practices, their consequences, and the legal framework designed to address them. Strategies for mitigating deception, such as regulatory reforms, ethics education, transparency initiatives, and whistleblower protections, are discussed. By advocating for a culture of accountability and integrity, this paper highlights the critical role of ethical adherence in safeguarding societal trust in the justice system.
... For example, Wheaton et al. found that schools with later start times reported improved sleep duration and better academic performance among students. Similarly, another study reviewed evidence regarding school start times (SSTs) and concluded that later start times were associated with better mood, reduced sleepiness, and improved overall health in adolescents (Ziporyn et al. 2022). ...
This systematic review explored school-based interventions for adolescents with the aim to improve sleep. The goal was to identify trends, pinpoint gaps and outline future directions. Five databases were searched, and paper sections were conducted following PRISMA guidelines. Randomized controlled trials focusing on non-pharmacological interventions in educational settings to improve sleep in adolescents aged 10–19 years were included. The risk of bias was assessed using Cochrane Rob2 tool. Sleep interventions yield promising results in the adolescent population. Despite these positive outcomes, there was variability in their impact on mental health, with no discernible effect on academic performance. The diversity in assessment tools and effectiveness across minority groups underscores the need for tailored approaches. While educational setting interventions show promise in improving adolescents’ sleep, there is a need for comprehensive, culturally sensitive approach. Future initiatives should address age-specific challenges, leverage technology, prioritize inclusivity and incorporate objective measures such as actigraphy.
... 38 In 2019, California became the first state to pass a law requiring all high schools and middle schools to start after 8:30 am and 8 am, respectively, which provides a model for other states to follow. 11 Education campaigns that reach stakeholders should be part of public health efforts to improve the overall health, well-being, and academic performance of sleep-deprived teens and provide them with sleep security. ...
Sleep is essential for a healthy, productive life, but access to sufficient and quality sleep is not universal. Sleep equity is influenced by both pathological and nonpathological sources. This article considers nonpathological determinants of adequate sleep, defines 3 features of sleep insecurity, and suggests how to promote sleep literacy to remove some barriers to adequate sleep, promote sleep equity, and improve individual and community health and well-being.
... In addition, beginning the school day at an early hour, when students are tired, harms their concentration and learning ability. Delaying the beginning of the school day to a later time improves adolescents' academic achievements, their mental health and the school climate (McKeever and Clark, 2017;Ziporyn et al., 2022). ...
Neuropedagogy, an interdisciplinary field at the nexus of neuroscience, psychology, and education, seeks to enhance teaching and learning processes. This paper advocates for the integration of neuropedagogical principles into teacher training, underscoring the pivotal role educators play in influencing students’ brain development. Incorporating neuroscientific knowledge in teaching can optimize educational outcomes. We explore key neuropedagogical principles, and highlight global developments in neuropedagogy. Three strategic avenues for integrating neuropedagogy in teacher training are proposed: promoting innovative teaching practices in teacher training, encouraging neuropedagogical research, and explicitly teaching neuroscientific knowledge to pre-service teachers. Our conclusion emphasizes the invaluable contribution of neuropedagogy to education and calls for its inclusion in pre-service teacher training.
... For this study, Twitter data was used. Although methodology recommendations were given by Ziporyn and other well-known sleep researchers (Ziporyn et al. 2022) and although Søilen, Tontini, and Aagerup established that an analysis of Twitter data can provide valuable information, Twitter users may not accurately represent the California population. An assumption made in this study is that the change in perception of SB328 before and after the bill's implementation is due to the bill's effect and impact. ...
Sleep deprivation among adolescents is a growing issue that threatens the health and academic success of students in the country. California Senate Bill 328 (SB328) is the first U.S. statewide legislation to delay school start times (SSTs), which can affect not only students but parents and teachers. Understanding how society perceives delayed SSTs is crucial for understanding how delayed SSTs impact the affected community and for ameliorating policies that delay SSTs. This study uses Twitter to investigate the perceptions of SB328 over time to see how the bill’s implication affected society’s views on SB328. This study finds that the perception of SB328 improved over time, but were overall negative.
... This impact could be especially deleterious for school children. Research shows that delaying school start times benefits students' sleep and daytime function, as well as reducing adolescent motor vehicle crash risk [20][21][22][23]. If DST becomes permanent, the benefit of the legislature to delay school start times could essentially be nullified. ...
Background: Permanent Daylight Savings Time (DST) may improve road safety by providing more daylight in the evening but could merely shift risk to morning commutes or increase risk due to fatigue and circadian misalignment. Methods: To identify how potential daylight exposure and fatigue risk could differ between permanent DST versus permanent Standard Time (ST) or current time arrangements (CTA), generic work and school schedules in five United States cities were modeled in SAFTE-FAST biomathematical modeling software. Commute data were categorized by morning (0700–0900) and evening (1600–1800) rush hours. Results: Percent darkness was greater under DST compared with ST for the total waking day (t = 2.59, p = 0.03) and sleep periods (t = 2.46, p = 0.045). Waketimes occurred before sunrise 63 ± 41% percent of the time under DST compared with CTA (42 ± 37%) or ST (33 ± 38%; F(2,74) = 76.37; p < 0.001). Percent darkness was greater during morning (16 ± 31%) and lower during evening rush hour (0 ± 0%) in DST compared with either CTA (morning: 7 ± 23%; evening: 7 ± 14%) or ST (morning: 7 ± 23%; evening: 7 ± 15%). Discussion: Morning rush hour overlaps with students’ commutes and shift workers’ reverse commutes, which may increase traffic congestion and risk compared with evening rush hour. Switching to permanent DST may be more disruptive than either switching to ST or keeping CTA without noticeable benefit to fatigue or potential daylight exposure.
... The developing adolescent brain is caught between the childhood need for sleep time (>9 hours), a shift from an early to late preferred phase of activity in the circadian "day," and rising social pressures and autonomy, all of which render adolescents and young adults susceptible to sleep deprivation. 161 Sleep deprivation, in turn, contributes to the activation of interictal epileptiform discharges and to the precipitation of seizures, especially in certain epilepsies such as juvenile myoclonic epilepsy. 162 Chronic insomnia affects more than a third of patients with epilepsy, and rising evidence shows that sleep hygiene and other measures to treat insomnia can improve seizure control and improve quality of life. ...
With more than 6000 attendees between in-person and virtual offerings, the American Epilepsy Society Meeting 2022 in Nashville, felt as busy as in prepandemic times. An ever-growing number of physicians, scientists, and allied health professionals gathered to learn a variety of topics about epilepsy. The program was carefully tailored to meet the needs of professionals with different interests and career stages. This article summarizes the different symposia presented at the meeting. Basic science lectures addressed the primary elements of seizure generation and pathophysiology of epilepsy in different disease states. Scientists congregated to learn about anti-seizure medications, mechanisms of action, and new tools to treat epilepsy including surgery and neurostimulation. Some symposia were also dedicated to discuss epilepsy comorbidities and practical issues regarding epilepsy care. An increasing number of patient advocates discussing their stories were intertwined within scientific activities.
Many smaller group sessions targeted more specific topics to encourage member participation, including Special Interest Groups, Investigator, and Skills Workshops. Special lectures included the renown Hoyer and Lombroso, an ILAE/IBE joint session, a spotlight on the impact of Dobbs v. Jackson on reproductive health in epilepsy, and a joint session with the NAEC on coding and reimbursement policies. The hot topics symposium was focused on traumatic brain injury and post-traumatic epilepsy.
A balanced collaboration with the industry allowed presentations of the latest pharmaceutical and engineering advances in satellite symposia.
... This impact could be especially deleterious for school children. Research shows that delaying school start times benefits students' sleep and daytime function, as well as reducing adolescent motor vehicle crash risk [24][25][26][27][28]. If DST becomes permanent, the benefit of legislature to delay school start times could essentially be nullified. ...
Background: Permanent Daylight Savings Time (DST) may improve road safety by providing more daylight in the evening but could merely shift risk to morning commutes or increase risk due to fatigue and circadian misalignment. Methods: To identify how potential daylight exposure and fatigue risk could differ between permanent DST versus permanent Standard Time (ST) or current time arrangements (CTA), generic work and school schedules in five United States cities were modeled in SAFTE-FAST biomathematical modeling software. Commute data were categorized by morning (0700-0900) and evening (1600-1800) rush hours. Results: Percent darkness was greater under DST compared to ST for the total waking day (t=2.59, p=0.03) and sleep periods (t=2.46, p=0.045). Waketimes occurred before sunrise 63%±41% percent of the time under DST compared to CTA (42%±37%) or ST (33%±38%; F(2, 74)=76.37; p<0.001). Percent darkness was greater during morning (16%±31%) and lower during evening rush hour (0%±0%) in DST compare to either CTA (morning:7%±23%; evening:7%±14%) or ST (morning:7%±23%; evening:7%±15%). Discussion: Morning rush hour overlapped with students’ commutes and shift worker reverse commutes, which may increase traffic congestion and risk compared to evening rush hour. Switching to permanent DST may be more disruptive than either switching to ST or keeping CTA without noticeable benefit to fatigue or potential daylight exposure.
... Evening chronotypes and sleep deprivation are very common in college students (e.g., Lund et al. 2010;Thacher 2008), with most students attributing their late nights and sleep loss to academic demands (e.g., Cho and Teran 2021;King et al. 2019). There is certainly abundant evidence that class start times can affect sleep and academic performance (e.g., Goldin et al. 2020;Ziporyn et al. 2022;Yeo et al. 2023; but see Gao et al. 2019). One of the mechanisms is the misalignment between adolescents' circadian timing systems and school times, with late chronotypes experiencing greater social jet lag (Touitou 2013). ...
Many students self-report that they are “night owls,” which can result from neurodevelopmental delays in the circadian timing system. However, whether an individual considers themselves to be an evening-type versus a morning-type (self-reported chronotype) may also be influenced by academic demands (e.g. class start times, course load) and behavioral habits (e.g. bedtime social media use, late caffeine consumption, daytime napping). If so, then chronotype should be malleable. We surveyed 858 undergraduate students enrolled in demanding science courses at up to three time points. The survey assessed morning/evening chronotype, global sleep quality, academics, and behavioral habits. Evening and morning-type students showed similar demographics, stress levels, and academic demands. At baseline measurements, relative to morning-types, evening-types showed significantly worse sleep quality and duration as well as 22% greater bedtime social media usage, 27% greater daytime napping duration, and 46% greater likelihood of consuming caffeine after 5pm. These behavioral habits partially mediated the effects of self-reported chronotype on sleep quality/duration, even after controlling for demographic factors. Interestingly, 54 students reported switching from being at least moderate evening-types at baseline to being at least moderate morning-types later in the semester and 56 students showed the reverse pattern (6.3% of students switched from “definitely” one chronotype to the other chronotype). Evening-to-morning “chrono-switchers” consumed less caffeine after 5pm and showed significantly better sleep quantity/quality at the later timepoint. Thus, some students may consider themselves to be night owls in part because they consume caffeine later, take more daytime naps, or use more social media at bedtime. Experimental work is needed to determine whether nudging night owls to behave like morning larks results in better sleep health or academic achievement.
... Differences across studies and schools could be related to school characteristics, sampling bias or methods for evaluating attendance and academic achievement. Nonetheless, the large body of correlational and interventional work on school start times and sleep health in adolescents has led many school districts to delay their start times 26 . ...
Attending classes and sleeping well are important for students’ academic success. Here, we tested whether early morning classes are associated with lower attendance, shorter sleep and poorer academic achievement by analysing university students’ digital traces. Wi-Fi connection logs in 23,391 students revealed that lecture attendance was about ten percentage points lower for classes at 08:00 compared with later start times. Diurnal patterns of Learning Management System logins in 39,458 students and actigraphy data in 181 students demonstrated that nocturnal sleep was an hour shorter for early classes because students woke up earlier than usual. Analyses of grades in 33,818 students showed that the number of days per week they had morning classes was negatively correlated with grade point average. These findings suggest concerning associations between early morning classes and learning outcomes.
... School night sleep is heavily influenced by fixed school schedules, in particular school start time. 36 The combination of a developmental shift towards delayed circadian timing in adolescence, and increasing autonomy to decide on bedtimes, 20,37 leads to sleep curtailment. In turn, the latter is associated with impaired learning, negative wellbeing outcomes and increased accidents. ...
... Schools with delayed start times have had varying amounts of success in terms of improvements on academic performance, but overall the consensus is in favor of delayed start times (Biller et al., 2022). California became the first state in 2019 to pass a law protecting adolescent sleep, requiring that middle schools start no earlier than 8:00 am and high schools no earlier than 8:30 am (Ziporyn et al., 2022). This law has a 3-year implementation period and provides more opportunity for researchers to determine how beneficial these changes are for students. ...
Media has become fundamentally integrated into the everyday lives of children and adolescents. Despite this, the consequences of media use on child and adolescent sleep remain incompletely understood. This chapter summarizes the current literature on four main mechanisms through which media consumption affects sleep health. (1) Increased media use is associated with decreased sleep duration secondary to sleep time displacement and delayed sleep onset. (2) Increased media use is associated with decreased sleep quality as a result of heightened arousal and greater sleep fragmentation. (3) Nighttime media use is associated with dysregulation of the circadian rhythm via blue light re-entrainment. (4) Mental health modulates both sleep and media use. Sleep and media use in-turn affect mental health, forming a bidirectional relationship. A biopsychosocial approach is taken to analyze each pathway. Key considerations such as age, sex, type of device used, passive vs. active use, and content of media are considered. Finally, evidence-based recommendations for clinicians, parents and policymakers are offered.
... School night sleep is heavily influenced by fixed school schedules, in particular school start time. 36 The combination of a developmental shift towards delayed circadian timing in adolescence, and increasing autonomy to decide on bedtimes, 20,37 leads to sleep curtailment. In turn, the latter is associated with impaired learning, negative wellbeing outcomes and increased accidents. ...
Objectives
Bedtime procrastination (BTP) refers to the tendency to delay sleep beyond an intended bedtime, in favor of continuing evening activities. BTP has been associated with negative sleep outcomes (later timing, shorter duration, poorer quality), and is viewed as a problem of exercising self-control. BTP could be particularly challenging in adolescents, given the combined effects of increasing bedtime autonomy, later chronotype, and a still developing self-control capacity. Thus far, research on BTP has only been based on self-report measures. Here we examined the influence of BTP on adolescent sleep, using objective measures of sleep.
Methods
About 121 adolescents aged 14-19 years completed a survey on BTP, sleep quality, chronotype, and mental health. Subsequently, habitual sleep was actigraphically monitored for up to 2 weeks, and participants completed a temporal discounting task (a proxy for impulsivity). Associations between BTP, chronotype, and actigraphy-measured sleep were examined for school nights and non-school nights separately.
Results
Greater BTP was associated with poorer subjective sleep, eveningness chronotype, and higher daytime fatigue, as well as higher anxiety/depression scores. Measured using actigraphy, greater BTP predicted later bedtimes and shorter sleep duration on school nights, even when controlling for chronotype. On non-school nights, eveningness chronotype, but not BTP, predicted later bedtimes and wake-up times. BTP was not correlated with temporal discounting.
Conclusions
Bedtime procrastination exerts significant influence on subjective and objective sleep measures in adolescents. Its effects are most prominent on school nights and can be separated from the effects of chronotype, which has stronger effects on sleep timing on non-school nights.
... The body of research indicating numerous health benefits for students by delaying school starts provoked an ongoing debate on adopting the delay (Marx et al., 2017;Ziporyn et al., 2021). Several obstacles are mentioned, predominantly on the adult sideadministrators, teachers, school staff members, and parents (Fitzpatrick et al., 2020). ...
Delayed school start times improve students’ sleep, but little is known about its impact on teachers. The Austrian COVID-19 lockdown created the unique opportunity to test the impact of a forced home office on Tyrolean teachers’ sleep. From April to May 2020, a cross-sectional and complete online survey was implemented with 2,314 Tyrolean teachers participating. Bedtimes and wake times on workdays and on weekends were measured before the lockdown (retrospectively) and during the lockdown. Additional variables were calculated: time spent in bed on workdays/weekends, social jetlag, and sleep loss. During the lockdown, as compared to the period before it, the teachers reported a longer sleep duration, decreased workday sleep loss, and reduced social jetlag. These effects occurred due to a delay in rise times on workdays and were enhanced in female and younger teachers. Changing to a home office during lockdown induced a robust drift towards later hours on workdays resulting in healthier sleep, indicating that teachers benefit from delayed school start times. Thus, the teachers adopted healthier workday sleep habits aligned to their biological sleep needs. In conclusion, not only adolescent students but also teachers benefit from a delayed school start. ----- This is the preprint version prior to peer review. The revised and improved article will be published in Chronobiology International with additional analyses regarding sample statistics and effects on school types.
... Unintended effects of the lifestyle changes during the COVID-19 pandemic, such as the shift to online learning, may have provided adolescents the opportunity to obtain longer and later sleep, although the majority of adolescents still obtained insufficient sleep during COVID-19. These findings may inform parents and policy makers as they consider shifting high schools schedules to start no earlier than 0830 h, in line with recommendations (Adolescent Sleep Working Group et al., 2014;Ziporyn et al., 2022). Continued efforts by clinicians to promote healthy sleep habits and inform adolescents of the potential benefits of obtaining healthy sleep remain important. ...
The majority of high school–aged adolescents obtain less than the recommended amount of sleep per night, in part because of imposed early school start times. Utilizing a naturalistic design, the present study evaluated changes in objective measurements of sleep, light, and physical activity before (baseline) and during the first wave of the COVID-19 pandemic (during COVID-19) in a group of US adolescents. Sixteen adolescents (aged 15.9 ± 1.2 years, 68.8% female) wore an actigraphy monitor for 7 consecutive days during an in-person week of school before the pandemic (October 2018-February 2020) and again during the pandemic when instruction was performed virtually (May 2020). Delayed weekday sleep onset times of 1.66 ± 1.33 h (p < 0.001) and increased sleep duration of 1 ± 0.87 h (p < 0.001) were observed during COVID-19 compared with baseline. Average lux was significantly higher during COVID-19 compared with baseline (p < 0.001). Weekday physical activity parameters were not altered during COVID-19 compared with baseline, except for a delay in the midpoint of the least active 5 h (p value = 0.044). This analysis provides insight into how introducing flexibility into the traditional school schedule might influence sleep in adolescents.
... While efforts to delay school start times for middle and high schools are slowly gaining traction [38,[56][57][58], additional strategies are needed, particularly for adolescents who have difficulty falling asleep early enough to get the recommended amount of sleep on school nights. Shifting the circadian system earlier should facilitate adolescents' ability to fall asleep earlier. ...
Study Objectives
Shift sleep onset earlier and extend school-night sleep duration of adolescents.
Methods
Forty-six adolescents (14.5-17.9 years; 24 females) with habitual short sleep (< 7h) and late bedtimes (≥ 23:00) on school nights slept as usual for two weeks (baseline). Then, there were three weekends and two sets of 5 weekdays in between. Circadian phase (Dim Light Melatonin Onset, DLMO) was measured in the laboratory on the first and third weekend. On weekdays, the “Intervention” group gradually advanced school-night bedtime (1 h earlier than baseline during week 1; 2 h earlier than baseline during week 2). Individualized evening time management plans (“Sleep RouTeen”) were developed to facilitate earlier bedtimes. On the second weekend, Intervention participants received bright light (~6000 lux; 2.5h) on both mornings. A control group completed the first and third weekend but not the second. They slept as usual and had no evening time management plan. Weekday sleep onset time and duration were derived from actigraphy.
Results
DLMO advanced more in the Intervention (0.6 ± 0.8h) compared to the Control (-0.1 ± 0.8h) group. By week 2, the Intervention group fell asleep 1.5 ± 0.7 h earlier and sleep duration increased by 1.2 ± 0.7 h; sleep did not systematically change in the Control group.
Conclusions
This multi-pronged circadian-based intervention effectively increased school-night sleep duration for adolescents reporting chronic sleep restriction. Adolescents with early circadian phases may only need a time management plan, whereas those with later phases probably need both time management and morning bright light.
... Despite changes to schedules and stressors related to COVID-19 (e.g., changes in school, reduced opportunities for physical activity and social interaction) that may have impacted sleep, the majority of adolescents reported improvements in sleep during COVID-19 with reduced social jetlag as well as increased time in bed. These findings support recent research that supports later school start times as a means of providing increased sleep opportunity for teens (Meltzer, Saletin et al., 2021;Meltzer et al., 2016;Ziporyn et al., 2022). ...
Objectives:
To assess changes in duration, timing, and social jetlag in adolescent sleep during the COVID-19 pandemic and evaluate the impact of mood, physical activity, and social interactions on sleep.
Study design:
An online survey queried adolescents' sleep before (through retrospective report) and during the initial phase of COVID-19 in May 2020. Adolescents (N = 3,494), 13-19 years old, in the United States (U.S.) answered questions about their current and retrospective (prior to COVID-19) sleep, chronotype, mood, and physical and social activities. Linear regression models were fit for time in bed, reported bed and wake times, and social jetlag during COVID-19, accounting for pre-COVID-19 values.
Results:
Total reported time in bed (a proxy for sleep duration) increased on weekdays by an average of 1.3 ± 1.8 hours (p < .001) during COVID-19, compared to retrospective report of time in bed prior to COVID-19. During COVID-19, 81.3% of adolescents reported spending 8 hours or more in bed on weekdays compared to only 53.5% prior to COVID-19. On weekdays, bedtimes were delayed on average by 2.5 hours and wake times by 3.8 hours during COVID-19 compared to prior to COVID-19. On weekends, bedtimes were delayed on average by 1.6 hours and waketimes by 1.5 hours (all p's < 0.001). Social jetlag of >2 hours decreased to 6.3% during COVID-19 compared to 52.1% prior to COVID-19. Anxiety and depression symptoms and a decline in physical activity during COVID-19 were associated with delayed bed and wake times during COVID-19.
Conclusions:
During COVID-19, adolescents reported spending more time in bed, with most adolescents reporting 8 hours of sleep opportunity and more consistent sleep schedules. As schools return to in-person learning, additional research should examine how sleep schedules may change due to school start times and what lessons can be learned from changes that occurred during COVID-19 that promote favorable adolescent sleep.
... Last, it should not be underestimated the potential ramifications, a permanent switch to daylight saving time would have on children and adolescents. For years, sleep and circadian experts have advocated for later school start times for K-12 education, because later start times can improve mood and academic performance, and reduce adverse behaviors (26). Morning light exposure has antidepressant effects (27) and permanent switch to daylight saving time would mean there would be certain parts of the United States where it would be dark/dusk until nearly 9:30 AM in some states on the westernmost edges of various time zones, leading to hours of wakefulness and school without natural light exposure in the morning. ...
In March 2022, the US Senate passed the Sunshine Protection Act that would abolish the biannual change in clocks each fall and spring and permanently adopt daylight saving time that aligns with the “spring forward” time change each March. A number of scientific and medical societies have endorsed the abolishment of the biannual clock change, but oppose the permanent adoption of daylight saving time. Instead, leading organizations such as the American Academy of Sleep Medicine (AASM) and the Society for Research on Biological Rhythms (SRBR) position statements highlight peer-reviewed evidence in favor of a permanent shift to standard time. The present perspectives will summarize some of the key AASM and SRBR recommendations, with a particular focus on the potential cardiovascular implications of a legislative change that would result in a permanent switch to either standard time or daylight saving time. Collectively, although there is building scientific consensus that abolishing the biannual time change has several sleep and circadian health benefits, the preponderance of evidence is opposite to the current legislation and instead suggests a permanent switch to standard time may offer the maximum health and safety benefits. This scientific evidence should be considered as the United States House of Representatives considers the Sunshine Protection Act.
Listen to this article's corresponding podcast at https://ajpheart.podbean.com/e/daylight-saving-time-and-cardiovascular-risk/ .
Purpose of the study: This paper investigates the relationship between mathematics achievement in the Trends in Mathematics and Science Study (TIMSS) and two key school achievement measures—grades and national test results—in Tunisia. Going beyond previous studies, this research also explores how these relationships differ across diverse student subgroups, providing a nuanced understanding of educational equity. Methodology:Give name, Employing robust statistical analyses, the study uncovers a strong positive correlation between TIMSS mathematics scores and both grade 6 and grade 9 achievement measures, underscoring TIMSS’s reliability as an indicator of student performance in the national context. Notably, students from more educated households consistently outperformed their peers from less-educated backgrounds on TIMSS, and the association between TIMSS scores and school achievement measures was significantly stronger for students from advantaged home environments. Main Findings: These findings suggest that socioeconomic factors and school contexts critically shape TIMSS performance, highlighting disparities in educational outcomes. Furthermore, the results call for a re-evaluation of how TIMSS data is interpreted and utilized in national education policies, especially in addressing inequities. By illuminating the complex interplay between individual backgrounds, school contexts, and standardized assessments, this study contributes to a deeper understanding of TIMSS as both a tool for measuring student achievement and a reflection of systemic challenges. Novelty/Originality of this study: These insights have profound implications for policymakers, educators, and researchers seeking to leverage TIMSS data for meaningful educational improvements while ensuring equity across diverse student populations.
Study objectives:
To examine the feasibility, acceptability, and impact of a Sleep Promotion Program (SPP).
Methods:
This pilot trial randomized adolescents (13-15y) with insufficient sleep duration and irregular sleep timing to SPP-continuation (n=24; SPP in month 1, continuation treatment in month 2) or monitoring-SPP (n=20; monitoring in month 1, SPP in month 2). SPP included one clinician session and at-home delivery of web-based reports of each youth's sleep diary data with accompanying intervention questions that prompt youth to engage in sleep behavior change. Attrition rate primarily measured feasibility. Program satisfaction measured acceptability. Total sleep time (TST), sleep timing, and sleep timing regularity were measured via sleep diary at baseline, follow-up 1, and follow-up 2 (each ∼1 month apart). Linear mixed effects models compared treatment arms on changes in sleep from baseline to follow-up 1 (month 1). We also compared changes in sleep during month 1 to changes in sleep during month 2 among SPP-continuation participants.
Results:
Attrition rate was 8.5%. 96.5% participants rated the quality of care received as good or excellent. In month 1, SPP-continuation youth showed a significantly greater increase in mean TST than monitoring-SPP youth (0.57 vs. -0.38 hours; contrast=0.95; CI=0.14, 1.76, p=0.024). SPP-continuation participants showed an increase in TST during month 1 (0.51h) but a decrease during month 2 (-0.74 h; contrast=-1.24, CI=-2.06, -0.42, p=0.005). No other significant effects were observed.
Conclusions:
SPP is highly feasible, acceptable, and associated with a significant increase in TST early in treatment.
Clinical trial registration:
Registry: ClinicalTrials.gov; Name: Targeted Intervention for Insufficient Sleep among Typically-Developing Adolescents; Identifier: NCT04163003; URL: https://clinicaltrials.gov/ct2/show/NCT04163003.
As alterações de sono e do ciclo sono/vigília (CSV) são problemas mundiais de saúde pública, sendo tema relevante para a Atenção Primária à Saúde (APS). Portanto, essa revisão analisou evidências sobre o CSV relacionadas às políticas de saúde no contexto da APS mundial (Nº Open Science Framework:10.17605/OSF.IO/S463X). Foram incluídos artigos no âmbito mundial (PubMed, Scopus e LILACS) e a literatura cinzenta considerada, foram os Cadernos de Atenção Básica (CAB), que são documentos importantes da APS no Brasil. Após as etapas de triagem, foram identificados 14 artigos que abordavam políticas de saúde internacionais sobre insônia; apneia do sono; programas ou folhetos de educação sobre o sono e qualidade de vida; clínica de sono; diretrizes; hábitos de vida e desempenho acadêmico; discussão sobre horário de aulas matutinas e relação da atividade física com o sono. No Brasil, foram mapeados 23 CAB, 9 orientava os profissionais de saúde a questionar sobre o sono dos usuários nos atendimentos; 8 descreviam o sono ou sonolência como efeito adverso de fármacos e 10 apontavam o sono como sintomas de outras condições de saúde. Os resultados apontam a importância de ações sobre sono no atendimento dos indivíduos que buscam a APS no Brasil e no mundo, a qual é cenário favorável ao desenvolvimento de ações de promoção à saúde.
Study Objectives
There is mixed evidence regarding associations of sleep duration with academic functioning in adolescents and a lack of research on other sleep dimensions, particularly using objective sleep measures. We examined associations of multiple actigraphic sleep dimensions with academic functioning among adolescents.
Methods
Data were from the sleep sub-study of the age 15 wave of the Future of Families and Child Wellbeing Study (n = 774–782; 52% female), a national, diverse sample of teens. Adolescents wore wrist-actigraphs for ~1 week and completed a survey reporting academic performance and school-related behavioral problems. Regression models assessed whether average sleep duration, timing, maintenance efficiency, and SD-variability were associated with self-reported academic functioning in cross-sectional analyses adjusted for demographic characteristics, depressive symptoms, and anxious symptoms.
Results
Later sleep timing (hours) and greater sleep variability (SD-hours) were associated with poorer academic outcomes, including sleep onset variability with higher odds of receiving a D or lower (OR = 1.29), sleep onset (β = −.07), sleep offset (β = −.08), and sleep duration variability (β = −.08) with fewer A grades, sleep offset with lower GPA (β = −.07), sleep offset (OR = 1.11), sleep duration variability (OR = 1.31), and sleep onset variability (OR = 1.42) with higher odds of being suspended or expelled in the past 2 years, and sleep duration variability with greater trouble at school (β = .13). Sleep duration, sleep maintenance efficiency, and sleep regularity index were not associated with academic functioning.
Conclusions
Later sleep timing and greater sleep variability are risk factors for certain academic problems among adolescents. Promoting sufficient, regular sleep timing across the week may improve adolescent academic functioning.
Introduction
The propensity for sleep shifts later as puberty progresses. The present analysis examines whether the circadian-dependent wake maintenance zone, or forbidden zone for sleep observed in the evening just before habitual bedtime is more pronounced in late to post-pubertal adolescents compared to adults and may partly explain late sleep onset in maturing adolescents.
Methods
Forty four healthy late/post-pubertal adolescents (aged 14.3–17.8 years, 23 female) and 44 healthy adults (aged 30.8–45.8 years, 21 female) participated in an ultradian light/dark protocol for 3 days cycling between 2-h wake periods (~20 lux) and 2-h nap periods (~0 lux) without external time cues. The dim light melatonin onset (DLMO), a measure of circadian phase, was measured immediately before the ultradian protocol by sampling saliva every 30 min in dim light. Wrist actigraphs were used to assess sleep onset latency and total sleep time during the naps that occurred during the ultradian sleep/wake schedule. Sleep episodes were grouped into 2-h bins relative to individual DLMOs (28–56 naps/bin). Sleep onset and total sleep time were compared between adolescents and adults as well as between males and females within each age group.
Results
Adolescents took significantly longer to fall asleep compared to adults during naps that occurred in the 4 h window surrounding the DLMO [2h before DLMO t (50) = 2.13, p = 0.04; 2 h after DLMO t (33) = 3.25, p = 0.003]. Adolescents also slept significantly less than adults during naps that occurred in the 4-h window surrounding DLMO [2 h before DLMO t (51) = −2.91, p = 0.01; 2 h after DLMO t (33) = −1.99, p = 0.05]. Adolescent males slept less than adolescent females in naps that occurred in the 2 h window after the DLMO [ t (14) = −2.24, p = 0.04].
Discussion
Compared to adults, late/post-pubertal adolescents showed greater difficulty falling asleep and maintaining sleep around the time of their DLMO, which usually occurs a few hours before habitual sleep onset. A greater amplitude in the circadian-driven forbidden zone for sleep could be an additional physiological mechanism explaining why maturing adolescents find it difficult to fall asleep early, increasing the risk for restricted sleep in the context of early school start times.
The recent original study by Morales-Ghinaglia et al. [1] reports a novel finding regarding the association between circadian misalignment and cardiometabolic health in adolescents. Among adolescents with circadian misalignment (represented as actigraphic assessment of sleep midpoint, variability of sleep midpoint, and social jetlag, a misalignment of sleep timing between school nights and weekends), there was a stronger positive association between visceral adiposity and metabolic syndrome than among adolescents without circadian misalignment. In other words, circadian misalignment exacerbated the association between visceral adiposity and metabolic syndrome in this adolescent sample. These results provide a clear message to adolescents, caregivers, clinicians, and policymakers: beyond the well-known benefits of sufficient sleep duration for a broad range of health outcomes, sleep timing and regularity may also influence adolescent health and well-being. Furthermore, adolescents with obesity or metabolic syndrome should be screened for circadian misalignment as a potential modifiable target for interventions that seek to improve cardiometabolic health.
Background
A public mental health lens is increasingly required to better understand the complex and multifactorial influences of interpersonal, community and institutional systems on the mental health of children and adolescents.
Methods
This research review (1) provides an overview of public mental health and proposes a new interactional schema that can guide research and practice, (2) summarises recent evidence on public mental health interventions for children and adolescents, (3) highlights current challenges for this population that might benefit from additional attention and (4) discusses methodological and conceptual hurdles and proposes potential solutions.
Results
In our evidence review, a broad range of universal, selective and indicated interventions with a variety of targets, mechanisms and settings were identified, some of which (most notably parenting programmes and various school‐based interventions) have demonstrated small‐to‐modest positive effects. Few, however, have achieved sustained mental health improvements.
Conclusions
There is an opportunity to re‐think how public mental health interventions are designed, evaluated and implemented. Deliberate design, encompassing careful consideration of the aims and population‐level impacts of interventions, complemented by measurement that embraces complexity through more in‐depth characterisation, or ‘phenotyping’, of interpersonal and environmental elements is needed. Opportunities to improve child and adolescent mental health outcomes are gaining unprecedented momentum. Innovative new methodology, heightened public awareness, institutional interest and supportive funding can enable enhanced study of public mental health that does not shy away from complexity.
Two proposed public policies, ending seasonal clock change with a transition to permanent Standard Time and moving middle school and high school start times later, are population-based initiatives to improve sleep health. Daylight Saving Time and early school start times are associated with reduced sleep duration and increased circadian misalignment, the effects of which impact not only long-term health outcomes including obesity, cerebrovascular and cardiovascular disease, and cancer, but also mental health, academics, workforce productivity, and safety outcomes. This article highlights studies that led to the endorsement of these public policies by multiple scientific and medical organizations. Neurologists should advocate at the state and federal levels and educate the population about the importance of sleep health.
Purpose of Review
Poor sleep health in adolescence has long-lasting, and adverse effects on many aspects of health and functioning. Multiple factors impact sleep in adolescence including individual and family-level factors. However, early school start times are the one policy-level, and possibly the most salient environmental factor that constrains adolescent sleep at a population level.
Recent Findings
Delaying school start times could be an effective strategy to promote sleep health and consequently, functioning, and physical and mental health among adolescents. Growing evidence suggests that adolescents at later-starting schools sleep longer on weekdays, have higher attendance and graduation rates, and fewer mental health symptoms compared to their peers at earlier-starting schools.
Summary
This paper reviews a summary of recent key findings and discusses future steps in translating the school start time research into policy.
The prevalence of sleep disorders has increased because of the fast-paced and stressful modern lifestyle, negatively impacting the quality of human life and work efficiency. It is crucial to address sleep problems. However, the current practice of diagnosing sleep disorders using polysomnography (PSG) has limitations such as complexity, large equipment, and low portability, hindering its practicality for daily use. To overcome these challenges, in this article an optical fiber sensor is proposed as a viable solution for sleep monitoring. This device offers benefits like low power consumption, non-invasiveness, absence of interference, and real-time health monitoring. We introduce the sensor with an optical fiber interferometer to capture ballistocardiography (BCG) and electrocardiogram (ECG) signals from the human body. Furthermore, a new machine learning method is proposed for sleep condition detection. Experimental results demonstrate the superior performance of this architecture and the proposed model in monitoring and assessing sleep quality.
In the US, few adolescents get adequate school night sleep, largely due to early school start times. In the START study we aimed to test the following hypothesis: That following the implementation of later high school start times students have lesser longitudinal increases in body mass index (BMI) and shift to more healthful weight-related behaviors relative to students attending schools that retain early start times. The study enrolled a cohort of students (n = 2426) in five high schools in the Twin Cities, MN metro. Heights and weights were measured objectively, and surveys were administered annually from 9th through 11th grades (2016-2018). All study schools started early (either 7:30 am or 7:45 am) at baseline (2016). At follow-up 1 (2017) and continuing through follow-up 2 (2018), two schools delayed their start times by 50-65 min, while three comparison schools started at 7:30 am throughout the observation period. Using a difference-in-differences natural experiment design, we estimated differences in changes in BMI and weight-related behaviors over time between policy change and comparison schools. Students' BMIs increased in parallel in both policy change and comparison schools over time. However relative to changes in comparison schools after the start time shift, students in policy change schools had a modestly more healthful profile of weight-related behaviors - for instance they had a relatively greater probability of eating breakfast, having supper with their family, getting more activity, eating fast food less frequently, and eating vegetables daily. Later start times could be a durable, population-wide strategy that promotes healthful weight behaviors.
Later circadian timing during adolescence is linked to worse sleep, more severe depression and greater alcohol involvement, perhaps due to circadian misalignment imposed by early school schedules. School schedules shifted later during the COVID-19 pandemic, ostensibly reducing circadian misalignment and potentially mitigating problems with depression and alcohol. We used the pandemic as a natural experiment to test whether adolescent drinkers with later circadian timing showed improvements in sleep, depression and alcohol involvement. Participants were 42 adolescents reporting alcohol use. We assessed circadian phase via dim light melatonin onset prior to the pandemic, then conducted remote assessments of sleep, depressive symptoms and alcohol use during the pandemic. Mixed-effects models were used to test for pandemic effects, covarying for age, sex, time since baseline evaluation, and current school/work status. Adolescents with later circadian timing reported less sleep than other teens on school nights, both before and during the pandemic. Although school night sleep increased during the pandemic (F = 28.36, p < 0.001), those increases were not greater for individuals with later circadian timing. Individuals with later circadian timing reported larger increases in alcohol use than other teens during the pandemic (X2 = 36.03, p < 0.001). Depressive symptoms increased during the pandemic (X2 = 46.51, p < 0.001) but did not differ based on circadian timing. Consistent with prior reports, adolescents with later circadian timing obtained less sleep, and later school schedules facilitated increased sleep duration. Nonetheless, individuals with later circadian timing reported the sharpest increases in alcohol use, suggesting that circadian timing contributes to risk for alcohol use beyond the effects of insufficient sleep.
Study objectives:
The current study was designed to examine if improvements in high school graduation and attendance rates persist four years after start times later than 8:30 am. Socioeconomic status and race were accounted for in the graduation analysis.
Methods:
School-wide attendance and graduation records (n=28 schools) from 1999-2017 were analyzed in August of 2021 using a repeated-measures analysis of variance at five points in time, one year pre-delay and four consecutive years post-delay start times.
Results:
Graduation rates for students in grade 12 (n>47,000) after post-delay year four increased from 80% to 90% (p<0.001) and attendance rates in grades 9-12 (n>80,000) improved from 90% to 93% (p=0.012).
Conclusions:
Attendance and graduation rates for all students improved after four years following a delayed start. Economically disadvantaged students and African-American students showed significant changes in graduation rates post-delay year four and White students significantly improved post-delay years 2, 3, and 4. Adolescent students, especially economically and racially disadvantaged students, have a vulnerability for obtaining adequate sleep. Delaying high school start times is a cost-effective intervention that could promote sufficient sleep and boost graduation and attendance rates.
The emergence of sleep precedes humanity and has always influenced human culture. The modern science of sleep and circadian rhythm medicine is foundationally based to address age old problems such as insomnia and nightmares. The pace of sleep scientific knowledge greatly accelerated with development of all-night sleep recordings and the subsequent illumination of the spectrum of clinical sleep disorders. Much of this fundamental work was influenced by Dr. William C. Dement and several other pioneers described in this article. The history of sleep and circadian science shows us the inexorable, and perhaps destined, path to know the functions of sleep and promote greater sleep health for society.
This study examined the effects of acute sleep restriction on the daytime behavior and performance of healthy children and adolescents. 82 participants (8 to 15 years of age) completed 5 nights of baseline sleep and were randomly assigned to Optimized (10 hr.) or Restricted (4 hr.) sleep for an overnight lab visit. Behavior, performance, and sleepiness were assessed the following day. Sleep restriction was associated with shorter daytime sleep latency, increased subjective sleepiness, and increased sleepy and inattentive behaviors but was not associated with increased hyperactive-impulsive behavior or impaired performance on tests of response inhibition and sustained attention. Results are discussed in terms of current theories regarding effects of inadequate or disturbed sleep among children and adolescents.
This cross-sectional study utilized responses from 46,537 students enrolled in grades 9 through 12 in 166 high schools across the state of Colorado via the 2019 Healthy Kids Colorado Survey to: (1) quantify the association between high school start times and student sleep duration and (2) investigate the associations between school start times and student mental health. Descriptive and bivariate analyses were used to investigate associations between school start times and self-reported demographic, sleep, and mental health factors. Survey-weighted multivariate regression modeling was used to investigate associations between school start times, sleep duration, and mental health. Schools with late start times (≥8:30 a.m.) saw 32.2% (95% Confidence Interval: 29.5–35.0) of students sleeping 8 h or more relative to 23.2% (22.0–24.4) in schools with very early start times (<8:00 a.m.). For every 15 min later school start time, students’ sleep duration was 4.6 (3.4–5.9) min longer. Students attending schools with very early start times had 1.10 (0.95–1.27) times the odds of attempting suicide compared to those attending schools with later start times, while students at schools with early starts (8:00–8:29 a.m.) were associated with 1.11 (0.98–1.27) times the odds. Schools with later school start times had a statistically significantly higher proportion of students sleeping 8+ hours. Schools with start times before 8:30 a.m. had 10–11% higher odds of students attempting suicide compared to schools with late start times, though these differences were not statistically significant. Student mental health should continue to be investigated when assessing the potential impacts of delayed school start times.
Purpose
In adolescence, physiological (circadian and homeostatic regulation of sleep) and social habits contribute to delayed sleep onset, while social obligations impose early sleep offset. The effects of delayed school start time on the subjective/objective measures of sleep–wake patterns and academic achievement have not been established.
Methods
This pre-, post-, and longitudinal non-randomized study included an early (8:00 am; ESC=30 students) and the late (9:00 am; LSC=21 students) start class. Multiple sleep data included a weekly sleep diary, Karolinska Sleepiness Scale, Pittsburgh Sleep Quality Index, and Epworth Sleepiness Scale. Sustained attention was measured using the Psychomotor Vigilance Task. Academic performance was evaluated by two different mathematical and scientific standard tests (entrance and final) and by school attendance indicators. Data were collected at monthly intervals from October 2018 to May 2019 and the beginning and end of the academic year (pre/post).
Results
All students turned their lights off at similar times (LSC=11:21pm, ESC=11:11pm), but LSC students woke up later (7:23am) than ESC students (6:55am; F1,48=11.81, p=0.001) on school days. The groups did not differ in total sleep duration on non-school days. Longitudinal measures revealed a significant increase (8.9%, 34 min) in total sleep duration of LSC students across the academic year. ESC students maintained approximately the same sleep duration. Furthermore, changes in sleep duration had parallelled significant differences in sustained attention, with LSC students outperforming ESC students. Longitudinal changes of sleep and sustained attention were associated with a coherent pattern of changes in academic performance.
Conclusion
Findings indicate that a one-hour delay in school start time is associated with longer sleep, better diurnal sustained attention, attendance, and improved academic performance. Notably, sleep changes were limited to school days. A delay in school start time should be seriously considered to improve sleep and academic achievements of students.
This open-access book examines the phenomenon of fake news by bringing together leading experts from different fields within psychology and related areas, and explores what has become a prominent feature of public discourse since the first Brexit referendum and the 2016 US election campaign. Thanks to funding from the Swiss National Science Foundation, all chapters can be downloaded free of charge at the publisher's website:
https://www.taylorfrancis.com/books/e/9780429295379
There is also an Amazon Kindle edition that's free of charge:
https://www.amazon.com/Psychology-Fake-News-Correcting-Misinformation-ebook-dp-B08FF54H53/dp/B08FF54H53/ref=mt_other?_encoding=UTF8&me=&qid=
In recent years, there has been a growing interest in understanding the relationship between sleep and suicide. Although sleep disturbances are commonly cited as critical risk factors for suicidal thoughts and behaviours, it is unclear to what degree sleep disturbances confer risk for suicide. The aim of this meta-analysis was to clarify the extent to which sleep disturbances serve as risk factors (i.e., longitudinal correlates) for suicidal thoughts and behaviours. Our analyses included 156 total effects drawn from 42 studies published between 1982 and 2019. We used a random effects model to analyse the overall effects of sleep disturbances on suicidal ideation, attempts, and death. We additionally explored potential moderators of these associations. Our results indicated that sleep disturbances are statistically significant, yet weak, risk factors for suicidal thoughts and behaviours. The strongest associations were found for insomnia, which significantly predicted suicide ideation (OR 2.10 [95% CI 1.83–2.41]), and nightmares, which significantly predicted suicide attempt (OR 1.81 [95% CI 1.12–2.92]). Given the low base rate of suicidal behaviours, our findings raise questions about the practicality of relying on sleep disturbances as warning signs for imminent suicide risk. Future research is necessary to uncover the causal mechanisms underlying the relationship between sleep disturbances and suicide.
Importance
Sleep is a resource that has been associated with health and well-being; however, sleep insufficiency is common among adolescents.
Objective
To examine how delaying school start time is associated with objectively assessed sleep duration, timing, and quality in a cohort of adolescents.
Design, Setting, and Participants
This observational cohort study took advantage of district-initiated modifications in the starting times of 5 public high schools in the metropolitan area of Minneapolis and St Paul, Minnesota. A total of 455 students were followed up from grade 9 (May 3 to June 3, 2016) through grade 11 (March 15 to May 21, 2018). Data were analyzed from February 1 to July 24, 2019.
Exposures
All 5 participating schools started early (7:30 am or 7:45 am) at baseline (2016). At follow-up 1 (2017) and continuing through follow-up 2 (2018), 2 schools delayed their start times by 50 and 65 minutes, whereas 3 comparison schools started at 7:30 am throughout the observation period.
Main Outcomes and Measures
Wrist actigraphy was used to derive indices of sleep duration, timing, and quality. With a difference-in-difference design, linear mixed-effects models were used to estimate differences in changes in sleep time between delayed-start and comparison schools.
Results
A total of 455 students were included in the analysis (among those identifying sex, 225 girls [49.5%] and 219 boys [48.1%]; mean [SD] age at baseline, 15.2 [0.3] years). Relative to the change observed in the comparison schools, students who attended delayed-start schools had an additional mean 41 (95% CI, 25-57) objectively measured minutes of night sleep at follow-up 1 and 43 (95% CI, 25-61) at follow-up 2. Delayed start times were not associated with falling asleep later on school nights at follow-ups, and students attending these schools had a mean difference-in-differences change in weekend night sleep of −24 (95% CI, −51 to 2) minutes from baseline to follow-up 1 and −34 (95% CI, −65 to −3) minutes from baseline to follow-up 2, relative to comparison school participants. Differences in differences for school night sleep onset, weekend sleep onset latency, sleep midpoints, sleep efficiency, and the sleep fragmentation index between the 2 conditions were minimal.
Conclusions and Relevance
This study found that delaying high school start times could extend adolescent school night sleep duration and lessen their need for catch-up sleep on weekends. These findings suggest that later start times could be a durable strategy for addressing population-wide adolescent sleep deficits.
The crucial role of sleep in physical and mental health is well known, especially during the developmental period. In recent years, there has been a growing interest in examining the relationship between sleep patterns and school performance in adolescents. At this stage of life, several environmental and biological factors may affect both circadian and homeostatic regulation of sleep. A large part of this population does not experience adequate sleep, leading to chronic sleep restriction and/or disrupted sleep–wake cycles. Studies investigating the effects of different sleep–wake schedules on academic achievement showed that impaired sleep quality and quantity are associated with decreased learning ability and compromised daytime functioning. This review focuses on the most recent studies that evaluated the effects of modified school start time on sleep patterns and related outcomes. Moreover, based on the available empirical evidence, we intend to propose a direction for future studies targeted to implement prevention or treatment programs by modifying sleep timing.
Improving adolescent sleep health is a national priority for ameliorating health and wellbeing (Healthy People 2020), as the majority of adolescents do not get the minimum recommended amount of 8 h of sleep per night. Prior research has identified sex and ethnoracial disparities in adolescent sleep but has been limited by data availability. National studies have collected reported sleep data, while objective sleep data has been available in community samples only. Using new data from adolescents in the Fragile Families and Child Wellbeing Study, a population-based birth cohort study of children born 1998–2000, we are able to characterize sex and ethnoracial disparities in sleep health in the first national sample of actigraphy-assessed sleep health among adolescents. In cross-sectional analyses, we use linear and logistic regression models to assess sex and ethnoracial disparities in weekday sleep duration, timing, and quality measured using actigraphy collected from 738 adolescents at approximately age 15. We identified sex and ethnoracial group differences in weekday and weekend adolescent sleep duration, with larger disparities in on weekends than weekdays. Male adolescents had 27-min shorter nightly sleep durations than females on weeknights. Non-Hispanic black adolescents had 32-min shorter nightly sleep durations than non-Hispanic whites on weekdays and 41-min shorter nightly sleep durations on weekends. While sex disparities persisted after accounting for naps, black-white differences were attenuated by napping such that there was no statistically significant black-white disparity in 24-h sleep on either weekdays or weekends. We did not identify disparities in sleep timing or quality. Future research should investigate the pathways through which these disparities arise, including behavioral, and contextual mechanisms.
Most adolescents exhibit very late chronotypes and attend school early in the morning, a misalignment that can affect their health and psychological well-being. Here we examine how the interaction between the chronotype and school timing of an individual influences academic performance, studying a unique sample of 753 Argentinian students who were randomly assigned to start school in the morning (07:45), afternoon (12:40) or evening (17:20). Although chronotypes tend to align partially with class time, this effect is insufficient to fully account for the differences with school start time. We show that (1) for morning-attending students, early chronotypes perform better than late chronotypes in all school subjects, an effect that is largest for maths; (2) this effect vanishes for students who attend school in the afternoon; and (3) late chronotypes benefit from evening classes. Together, these results demonstrate that academic performance is improved when school times are better aligned with the biological rhythms of adolescents.
Circadian rhythms are internal manifestations of the solar day that permit adaptations to predictable environmental temporal changes. These ~24-h rhythms are controlled by molecular clockworks within the brain that are reset daily to precisely 24 h by exposure to the light-dark cycle. Information from the master clock in the mammalian hypothalamus conveys temporal information to the entire body via humoral and neural communication. A bidirectional relationship exists between mood disorders and circadian rhythms. Mood disorders are often associated with disrupted circadian clock-controlled responses, such as sleep and cortisol secretion, whereas disruption of circadian rhythms via jet lag, night-shift work, or exposure to artificial light at night, can precipitate or exacerbate affective symptoms in susceptible individuals. Evidence suggests strong associations between circadian rhythms and mental health, but only recently have studies begun to discover the direct interactions between the circadian system and mood regulation. This review provides an overview of disrupted circadian rhythms and the relationship to behavioral health and psychiatry. The focus of this review is delineating the role of disruption of circadian rhythms on mood disorders using human night shift studies, as well as jet lag studies to identify links. We also review animal models of disrupted circadian rhythms on affective responses. Lastly, we propose low-cost behavioral and lifestyle changes to improve circadian rhythms and presumably behavioral health.
Adolescents are at risk of sleep deficit, which has serious consequences for their daytime functioning. However, school-based interventions to improve sleep have shown limited success. This might be due to the content of the programs (e.g., not targeting central factors such as daytime stress and technology use) or that changes have not been captured due to a lack of long-term follow-ups. Hence, the aim of this study was to evaluate the long-term effects of a school-based sleep education curriculum including time management training.
The study used a quasi-experimental design. Participants were 3622 adolescents (mean age 13.7, 48% girls), 286 in the intervention group and 3336 were followed as a natural control group. Data were collected before the intervention and at a one-year follow-up.
We divided participants into three groups, according to baseline sleep duration (calculated from self-reported bed- and wake-times, minus sleep onset latency); insufficient (< 7 h), borderline (7-8 h) and adequate (> 8 h). Adolescents in the intervention group were ~2 times less likely to report insufficient sleep at follow-up as compared to controls. Sleep knowledge improved significantly in the intervention group but there were no changes in emotional sleep hygiene (e.g., bedtime worry) and perceived stress. Surprisingly, technology use increased and behavioral sleep hygiene worsened in the intervention group.
Although the mechanisms of change need further investigation, the results of this study point at potential long-term benefits of school-based sleep programs.
Keywords: Sleep health, youths, Information and Communication Technology (ICT), prevention.
Objective:
The current study examines longitudinal sleep patterns in relation to risky sexual behaviors in a racially/ethnically diverse sample of adolescents.
Method:
The sample comprises 1,850 youth (mean age at first wave = 16.21; 57% female). Sleep duration, sleep variability (difference between weekend and weekday sleep duration), and sleep quality were collected over four annual assessments from 2013 to 2017. Risky sexual behaviors (i.e., sex without condom use or sex after using drugs or alcohol) were examined at the fourth follow-up assessment when youth were 19 years old. Longitudinal latent class analysis characterized patterns of individual sleep dimensions over time, as well as the combination of sleep dimensions, and examined how emergent sleep classes associated with subsequent risky sexual behavior, after adjustment for sociodemographics and mental health.
Results:
After covariate adjustment, persistent "short" weekend sleepers were 2.2 times more likely to engage in risky sexual behaviors, compared to youth with sufficient weekend sleep duration. Contrary to expectations, adolescents with more consistent weekend/weekday sleep were 1.6-2 times more likely to engage in risky sexual behaviors, compared to those with greater variability; however, lack of variability may be an indicator of chronic insufficient sleep, both weekdays and weekends. There were no significant differences in risky sexual behavior according to classes of weekday sleep duration or quality. In the combined class model, those with persistently short and poor-quality sleep were at marginally greater risk for engaging in risky sexual behaviors.
Conclusion:
Insufficient sleep in adolescents may increase risk for sexual risk-taking and may set the stage for accelerated health risk trajectories into adulthood. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
Sleep and immunity are bidirectionally linked. Immune system activation alters sleep, and sleep in turn affects the innate and adaptive arm of our body's defense system. Stimulation of the immune system by microbial challenges triggers an inflammatory response, which, depending on its magnitude and time course, can induce an increase in sleep duration and intensity, but also a disruption of sleep. Enhancement of sleep during an infection is assumed to feedback to the immune system to promote host defense. Indeed, sleep affects various immune parameters, is associated with a reduced infection risk, and can improve infection outcome and vaccination responses. The induction of a hormonal constellation that supports immune functions is one likely mechanism underlying the immune-supporting effects of sleep. In the absence of an infectious challenge, sleep appears to promote inflammatory homeostasis through effects on several inflammatory mediators, such as cytokines. This notion is supported by findings that prolonged sleep deficiency (e.g., short sleep duration, sleep disturbance) can lead to chronic, systemic low-grade inflammation and is associated with various diseases that have an inflammatory component, like diabetes, atherosclerosis, and neurodegeneration. Here, we review available data on this regulatory sleep-immune crosstalk, point out methodological challenges, and suggest questions open for future research.
Introduction
Sleep deficiency and poor sleep hygiene are common among college students. These modifiable factors contribute to adverse mental health, physical health, and academic performance. Sleep health education has been shown to change behavior, improve sleep quality, and reduce the risk of depression. We sought to compare methods of delivering sleep health education to determine which approach optimizes engagement of the student population.
Methods
A 45-minute, interactive, online sleep health education program (Sleep 101) was developed to provide college students with a comprehensive understanding of the ways in which sleep impacts health, mood, performance, and safety. The education also included strategies to optimize sleep during college. We provided the online, interactive sleep health education to three separate student groups using different approaches: 1) a mid-semester voluntary activity encouraged with a monetary incentive [) for upper-class undergraduate students, promoted through in-person solicitations outside campus dining areas, newsletter notices and emailed invitations; 2) a pre-matriculation (PMA) activity with a deadline and implied requirement for first-year undergraduate students; or 3) a mid-semester assigned (MSA) activity with a deadline and implied requirement for upper-class undergraduate students. Students were allowed 2 weeks to complete the online sleep health education after it was assigned by the Dean’s office. We compared participation rates for each method using descriptive statistics.
Results
The MSV$, PMA and MSA methods yielded a 4% (17 of 391), 90% (1,500 of 1,688) and 25% (1,238 of 5,025) completion rate, respectively.
Conclusion
The pre-matriculation assigned method for distribution of an undergraduate sleep health education program resulted in the highest engagement. Colleges should consider including sleep health education as a component of assigned pre-matriculation education, as is common for other student health concerns.
Support (If Any)
Mary Ann & Stanley Snider via Combined Jewish Philanthropies, NIH R01-GM-105018,K24-HL-105664 (EBK).
BACKGROUND
Sleep duration and sport specialization have been shown to affect injury profile in young athletes. The interplay between training hours per week, and, multiple versus single sports participation on sleep hours in young athletes is unknown. Purpose/Objective To investigate associations between single sport participation and training volume, with sleep hours, in pediatric and adolescent athletes.
METHODS
Study design: Cross-sectional epidemiological study was conducted using electronic questionnaire data from an injury prevention evaluation (IPE) at a sports injury prevention center affiliated with a tertiary level pediatric medical center between April 2013 and February 2018. Data analysis included sports participation, previous injury history, training regimen, and sleeping habits. For each sport selected, athletes were asked about average number of practice hours for each sport and number of seasons training for the sport during the year. All athletes aged 11-18 years were included in the study. Main outcome measures include sleep duration, single sport, and training hours/seasons. Single sport athletes were defined as those athletes who listed participation in only one sport year-round. Binary measures were created to indicate 1)any participant that listed practicing > 10 hour/week for any sport during a season and 2) any participant that trains three or more seasons for any sport in which they participate. Multivariate regression models (M1, M2, M3) were created for soccer athletes to control for sport training differences while testing the independent effect of gender, age and sport training. Based on the results univariate linear regression of hours of sleep was stratified by age and gender and regressed by self-reported hours of practice per week, identification as single sport athlete, training three or more seasons for soccer.
RESULTS
There were 756 athletes, 11-18 years old, included (mean age 13.5±2.5 years; 56% female (N=426)). For female athletes, figure skating (46%, 11/24), dance (42%, 28/67), and gymnastics (25%, 12/47) lead the list for single sport athletes. In comparison, for male athletes, swimming (26%, 5/19), tennis (19%, 5/26) and soccer (13%, 16/120) lead the list. The overwhelming majority of gymnasts, dancers, and figure skaters (88% (38/43), 83% (54/66) and 83%, (20/24)) train = 3 seasons of the year. In comparison, for male athletes, tennis athletes (62%, 16/25) seem to train = 3 seasons of the year followed by soccer (41%, 49/119) and swimming (39%, 7/18). (Tables 1 and 2) Table 3 presents multivariate linear regression coefficient of weeknight hours slept by practice hours, gender, age and sport characteristics for soccer participants using three different models (M1, M2, M3). Younger athletes, ages 11-14 years, slept nearly an hour more than participants aged 15-18 years across all training types. Only female soccer athletes training = 3 seasons slept significantly less (ß -0.24, SE 0.12, 95%) than their male counterparts. Participants that practiced soccer > 10 hours/week slept significantly, and substantively, less than their peers practicing =3 or less hours/week (ß -0.61, SE 0.17, 95%). Table 4 presents all participants and sport type stratified by age and sex. Practicing more than 10 hours/week was significant in males ages 11-14 years. Middle school aged males, practicing > 10 hours/week for any sport in which they participate over the course of the year, slept over half an hour less than their peers that practiced fewer hours (ß -0.65, SE 0.2, 95%).
CONCLUSIONS/SIGNIFICANCE
Training volume appears to affect sleep in young athletes. Middle school male athletes practicing greater than 10 hours/week appear to sleep less than their peers. Anticipatory guidance surrounding training may help to improve sleep hygiene in pediatric and adolescent athletes. [Table: see text][Table: see text][Table: see text][Table: see text]
There is overwhelming evidence that sleep is crucial for memory consolidation. Patients with schizophrenia and their unaffected relatives have a specific deficit in sleep spindles, a defining oscillation of non-rapid eye movement (NREM) Stage 2 sleep that, in coordination with other NREM oscillations, mediate memory consolidation. In schizophrenia, the spindle deficit correlates with impaired sleep-dependent memory consolidation, positive symptoms, and abnormal thalamocortical connectivity. These relations point to dysfunction of the thalamic reticular nucleus (TRN), which generates spindles, gates the relay of sensory information to the cortex, and modulates thalamocortical communication. Genetic studies are beginning to provide clues to possible neurodevelopmental origins of TRN-mediated thalamocortical circuit dysfunction and to identify novel targets for treating the related memory deficits and symptoms. By forging empirical links in causal chains from risk genes to thalamocortical circuit dysfunction, spindle deficits, memory impairment, symptoms, and diagnosis, future research can advance our mechanistic understanding, treatment, and prevention of schizophrenia. Expected final online publication date for the Annual Review of Clinical Psychology Volume 15 is May 7, 2019. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.
Most teenagers are chronically sleep deprived. One strategy proposed to lengthen adolescent sleep is to delay secondary school start times. This would allow students to wake up later without shifting their bedtime, which is biologically determined by the circadian clock, resulting in a net increase in sleep. So far, there is no objective quantitative data showing that a single intervention such as delaying the school start time significantly increases daily sleep. The Seattle School District delayed the secondary school start time by nearly an hour. We carried out a pre-/post-research study and show that there was an increase in the daily median sleep duration of 34 min, associated with a 4.5% increase in the median grades of the students and an improvement in attendance.
We contribute to the school start time literature by using statewide student-level data from North Carolina to estimate start time effects for all students and for traditionally disadvantaged students. Descriptively, we found that urban high schools were likely to start very early or late. Later start times were associated with positive student engagement outcomes (reduced suspensions, higher course grades), especially for disadvantaged students. Achievement results were mixed, with positive and negative associations between start times and high school students’ test scores. Continued research is necessary to evaluate the efficacy of later start times as a scalable and cost-effective approach for boosting engagement and achievement.
Objective:
Later school start times for adolescents have been implemented in the US and associated benefits found, although no randomised controlled trials (RCT) have been undertaken. The objective of this study was to evaluate the impact of two school interventions in the UK, a delayed start time and a sleep education programme, on students' academic performance, sleep outcomes and health-related quality of life.
Methods:
The study had an RCT design to enable an investigation into the differential effects of two interventions or a combination of both: schools were to delay their start time to 10:00am and/or provide a classroom-based sleep education programme. The recruitment target was 100 state (non-fee-paying) secondary schools. Participants were to be students in Year 10/11 (14-16-year-olds).
Results:
Despite much media coverage, only two schools volunteered to take part in the RCT. The main challenges faced in recruitment fell under three categories: research design, school, and project-specific issues. The delayed start time and prospect of randomisation to this intervention were the overwhelming reasons cited for not taking part. Facilitators and barriers to research were identified. Recommendations include carrying out a feasibility study prior to a main trial, allowing adequate time for recruitment, involving stakeholders throughout the decision-making process, incorporating independent (fee-paying) schools in recruitment, focusing on students not taking important examinations or involving an older year group with greater independence.
Conclusion:
The Teensleep study provides supporting evidence that evaluating the effects of a change in school start times through an RCT is unfeasible in the UK.
Study Objectives
High school start times (SSTs) directly impact adolescents’ sleep timing and duration. This study investigated the associations between SSTs and actigraphically-measured 24-hour sleep duration, sleep onset, sleep offset and sleep quality.
Methods
This study included 383 adolescents (Mage=15.5, SDage=0.6 years) participating in the age 15 wave of the Fragile Families & Child Wellbeing Study, a national birth cohort study sampling from 20 large U.S. cities. Multilevel models used daily observations (N=1,116 school days, Mdays =2.9, SDdays=1.4 per adolescent) of sleep and SSTs from concordant daily diary and actigraphy.
Results
A diverse range of SSTs were included in our analyses (MSST=8:08, SDSST=39 minutes, RangeSST=6:00-11:05), and are presented in the following categories for ease of interpretation: before 7:30, 7:30–7:59, 8:00-8:29, and 8:30 or later. Adolescents starting school at 8:30 or later exhibited significantly longer actigraphically-assessed 24-hour sleep duration (by 21–34 minutes, p<.05) and later sleep offset (by 32–64 minutes, p<.001) when compared with the adolescents grouped by earlier SSTs. SSTs were also analyzed continuously for comparison with existing literature, and results indicated that every one-hour delay in SST was significantly associated with 21 minutes longer 24-hour sleep duration (p<.001), 16 minutes later sleep onset (p<.01), and 39 minutes later sleep offset (p<.001). All models controlled for covariates including socioeconomic status.
Conclusion
These findings support pediatric and public health expert recommendations for SSTs after 8:30 a.m. In our diverse national urban sample, adolescents with SSTs at 8:30 or later, compared with adolescents with earlier SSTs, had significantly longer actigraphy-measured sleep.
Purpose of Review
Later school start times are associated with a number of benefits for adolescents. The purpose of the current review is to summarize the literature regarding the effects of delaying school start times on adolescent psychological health.
Recent Findings
We identified eight observational studies that examined the relationship between schools’ starting times and psychological outcomes. Of these, three were longitudinal studies that reported measures of adolescent mental health improved following a start time delay. Two cross-sectional studies showed that mental health scores were higher in schools with later compared to earlier start times. Three studies found no relationship between start time and mental health.
Summary
In the majority of studies reviewed, later school start times were associated with greater adolescent psychological health. However, inherent design drawbacks in the studies prevent us from concluding that these associations are causal. There are a wide range of potential benefits, beyond mental health, that later high school start times offer. This encouraging, emergent literature on delayed start times has led many school districts to consider changes to their start times.
Study Objectives
To investigate the short- and longer-term impact of a 45-min delay in school start time on sleep and well-being of adolescents.
Methods
The sample consisted of 375 students in grades 7–10 (mean age ± SD: 14.6 ± 1.15 years) from an all-girls’ secondary school in Singapore that delayed its start time from 07:30 to 08:15. Self-reports of sleep timing, sleepiness, and well-being (depressive symptoms and mood) were obtained at baseline prior to the delay, and at approximately 1 and 9 months after the delay. Total sleep time (TST) was evaluated via actigraphy.
Results
After 1 month, bedtimes on school nights were delayed by 9.0 min, while rise times were delayed by 31.6 min, resulting in an increase in time in bed (TIB) of 23.2 min. After 9 months, the increase in TIB was sustained, and TST increased by 10.0 min relative to baseline. Participants also reported lower levels of subjective sleepiness and improvement in well-being at both follow-ups. Notably, greater increase in sleep duration on school nights was associated with greater improvement in alertness and well-being.
Conclusions
Delaying school start time can result in sustained benefits on sleep duration, daytime alertness, and mental well-being even within a culture where trading sleep for academic success is widespread.
Misalignments between endogenous circadian rhythms and the built environment (i.e., social jet lag, SJL) result in learning and attention deficits. Currently, there is no way to assess the impact of SJL on learning outcomes of large populations as a response to schedule choices, let alone to assess which individuals are most negatively impacted by these choices. We analyzed two years of learning management system login events for 14,894 Northeastern Illinois University (NEIU) students to investigate the capacity of such systems as tools for mapping the impact of SJL over large populations while maintaining the ability to generate insights about individuals. Personal daily activity profiles were validated against known biological timing effects, and revealed a majority of students experience more than 30 minutes of SJL on average, with greater amplitude correlating strongly with a significant decrease in academic performance, especially in people with later apparent chronotypes. Our findings demonstrate that online records can be used to map individual- and population-level SJL, allow deep mining for patterns across demographics, and could guide schedule choices in an effort to minimize SJL's negative impact on learning outcomes.
Insufficient sleep among children and adolescents is associated with increased risk for obesity, diabetes, injuries, poor mental health, attention and behavior problems, and poor academic performance (1-4). The American Academy of Sleep Medicine has recommended that, for optimal health, children aged 6-12 years should regularly sleep 9-12 hours per 24 hours and teens aged 13-18 years should sleep 8-10 hours per 24 hours (1). CDC analyzed data from the 2015 national, state, and large urban school district Youth Risk Behavior Surveys (YRBSs) to determine the prevalence of short sleep duration (<9 hours for children aged 6-12 years and <8 hours for teens aged 13-18 years) on school nights among middle school and high school students in the United States. In nine states that conducted the middle school YRBS and included a question about sleep duration in their questionnaire, the prevalence of short sleep duration among middle school students was 57.8%, with state-level estimates ranging from 50.2% (New Mexico) to 64.7% (Kentucky). The prevalence of short sleep duration among high school students in the national YRBS was 72.7%. State-level estimates of short sleep duration for the 30 states that conducted the high school YRBS and included a question about sleep duration in their questionnaire ranged from 61.8% (South Dakota) to 82.5% (West Virginia). The large percentage of middle school and high school students who do not get enough sleep on school nights suggests a need for promoting sleep health in schools and at home and delaying school start times to permit students adequate time for sleep.
Objectives
To investigate adolescent sleep parameters and predictors during COVID-19-related school closures.
Methods
Original data were analyzed from a cross-sectional online survey of 590 teens in grades 6-12 attending school remotely in 35 US states, in May/June 2020.
Results
Students reported waking up 2.1-2.9 hours later during school closures and averaged 7.9-8.7 hours of sleep and 8.6-9.5 hours in bed on school nights. Compared to middle schoolers, high school students had later bed and wake times, accompanied by spending less time in bed and less time sleeping. The delay in wake time after school closures was also longer for high school students than for middle schoolers. Students with later class start times went to bed later, but also woke up later, slept longer, and spent more time in bed. When comparing intraindividual sleep before and after school closures, later class start times resulted in greater delays in wake time and greater odds of increased sleep duration. In addition, parent-set bedtimes were associated with earlier bedtimes and longer sleep duration during school closures.
Conclusions
As a result of COVID-19-related school closures and remote instruction, more middle and high school students achieved recommended amounts of sleep, primarily by waking up later in the morning. This study supports previous evidence that morning start schedule affects adolescent sleep behaviors. The implications of this study extend beyond COVID-19 school closures; adolescent sleep health improves with later school start times and fewer scheduled morning activities.
Study Objectives
To examine associations among instructional approaches, school start times, and sleep during the COVID-19 pandemic in a large, nationwide sample of U.S. adolescents.
Methods
Cross-sectional, anonymous self-report survey study of a community-dwelling sample of adolescents (grades 6–12), recruited through social media outlets in October/November 2020. Participants reported on instructional approach (in-person, online/synchronous, online/asynchronous) for each weekday (past week), school start times (in-person or online/synchronous days), and bedtimes (BT) and wake times (WT) for each identified school type and weekends/no school days. Sleep opportunity was calculated as BT-to-WT interval. Night-to-night sleep variability was calculated with mean square successive differences.
Results
Respondents included 5,245 racially and geographically diverse students (~50% female). BT and WT were earliest for in-person instruction; followed by online/synchronous days. Sleep opportunity was longer on individual nights students did not have scheduled instruction (>1.5 h longer for online/asynchronous than in-person). More students obtained sufficient sleep with later school start times. However, even with the same start times, more students with online/synchronous instruction obtained sufficient sleep than in-person instruction. Significantly greater night-to-night variability in sleep-wake patterns was observed for students with in-person hybrid schedules versus students with online/synchronous + asynchronous schedules.
Conclusions
These findings provide important insights regarding the association between instructional approach and school start times on the timing, amount, and variability of sleep in U.S. adolescents. Given the public health consequences of short and variable sleep in adolescents, results may be useful for education and health policy decision-making for post-pandemic secondary schools.
Introduction
Early high school start times are associated with insufficient adolescent sleep, which in turn is associated with motor vehicle crashes [MVC]. This analysis examined the impact of a 70-minute delay in high school start times on student-reported drowsy driving and department of transportation MVC rates before and for 2 years after start time changes.
Methods
Self-reported sleep duration and drowsy driving data were drawn from a longitudinal study of changing high school start times (n=2099–4092/year) in the Cherry Creek School District (Arapahoe County [AC]). The Colorado Department of Transportation provided frequency/timing of weekday MVC data for teen (16–18 years) and adult drivers in AC and four neighboring counties in metro Denver (Other Counties [OC]). MVC rates per 1000 licensed drivers were calculated. Outcomes are reported for three school years: 2016–17 (pre-change), 2017–18 (post change), and 2018–19 (follow-up). Chi-square analyses examined drowsy driving frequency (at least once/week vs. less than once/week) by sufficient weeknight sleep duration (<8 hours vs. 8+ hours). Two-proportion z-tests compared MVC rates by county, as well as teens vs. adults.
Results
Compared to pre-change (29.3%), fewer students reported drowsy driving at post-change (20.3%) and follow-up (23.7%). Students who reported insufficient sleep also reported more frequent drowsy driving across all years (p’s<0.001 to 0.037). AC’s teen crash rate decreased from 78.9/1000 to 76.6/1000 post-change, with a further reduction to 68.7/1000 at follow-up. Pre-change crash rates did not differ between counties (p=0.444); however, they were significantly lower in AC vs. OC at both post-change (p=0.048) and follow-up (p=0.046). Adult crash rates remained consistent over three years in both counties. Morning crash rates per hour did not differ pre-change; at both post-change and follow-up OC’s morning crash rates peaked one hour earlier than AC’s (7:00-7:59am vs. 8:00-8:59am).
Conclusion
This study extends previous reports by finding that later school start times are associated with decreased drowsy driving and fewer teen motor vehicle crash rates for up to 2 years post-change. Early school start times is an important public policy that benefits adolescent sleep, health, and well-being through decreased drowsy driving and motor vehicle crashes.
Support (if any)
Robert Wood Johnson Foundation’s Evidence for Action Program
Introduction
The COVID-19 pandemic significantly disrupted how and when adolescents attended school. This analysis used data from the Nationwide Education and Sleep in TEens During COVID (NESTED) study to examine the association of instructional format (in-person, virtual, hybrid), school start times, and sleep in a large diverse sample of adolescents from across the U.S.
Methods
In October/November 2020, 5346 nationally representative students (grades 6–12, 49.8% female, 30.6% non-White) completed online surveys. For each weekday, participants identified if they attended school in person (IP), online-scheduled synchronous classes (O/S), online-no scheduled classes (asynchronous, O/A), or no school. Students reported school start times for IP or O/S days, and bedtimes (BT) and wake times (WT) for each applicable school type and weekends/no school days (WE). Sleep opportunity (SlpOpp, total sleep time proxy) was calculated from BT and WT. Night-to-night sleep variability was calculated with mean square successive differences.
Results
Significant differences for teens’ sleep across instructional formats were found for all three sleep variables. With scheduled instructional formats (IP and O/S), students reported earlier BT (IP=10:54pm, O/S=11:24pm, O/A=11:36pm, WE=12:30am), earlier WT (IP=6:18am, O/S=7:36am, O/A=8:48am, WE=9:36am), and shorter SlpOpp (IP=7.4h, O/S=8.2h, O/A=9.2h, WE=9.2h). Small differences in BT, but large differences in WT were found, based on school start times, with significantly later wake times associated with later start times. Students also reported later WT on O/S days vs. IP days, even with the same start times. Overall, more students reported obtaining sufficient SlpOpp (>8h) for O/S vs. IP format (IP=40.0%, O/S=58.8%); when school started at/after 8:30am, sufficient SlpOpp was even more common (IP=52.7%, O/S=72.7%). Greater night-to-night variability was found for WT and SlpOpp for students with hybrid schedules with >1 day IP and >1 day online vs virtual schedules (O/S and O/A only), with no differences in BT variability reported between groups.
Conclusion
This large study of diverse adolescents from across the U.S. found scheduled school start times were associated with early wake times and shorter sleep opportunity, with greatest variability for hybrid instruction. Study results may be useful for educators and policy makers who are considering what education will look like post-pandemic.
Support (if any):
Objective
To evaluate the sleep habits of school-going children before and during school closure in the national lockdown period (called ‘Circuit Breaker’ or CB in Singapore) due to the COVID-19 pandemic.
Methods
Cross-sectional, anonymous, online, population-based survey questionnaire was administered to parents aged 21 years and above with children aged between 3 to 16 years attending pre-school, primary or secondary school (equivalent to kindergarten, middle and-high school) and residing in Singapore. Sleep duration in relation to various daily activities including academic activities, physical exercise, and screen time was evaluated pre-CB and during CB.
Results
Data from 593 participants were analyzed. Pre-CB, the overall mean (SD) sleep duration of the study population was 9.01 (1.18) hours on weekdays and 9.99 (0.94) hours on weekends. During CB, mean (SD) sleep duration overall was 9.63 (1.18) hours. Although children generally went to bed later (mean 0.65 hours later), they woke up even later during CB (mean 1.27 hours later), resulting in longer sleep duration (mean increase of 0.35 hours). This was most evident in secondary school children (mean increase of 0.70 hours). Children attending private schools (which had later start times) had increased sleep duration (mean 10.01 (SD 0.89) hours pre-CB and 10.05 (SD 0.93) hours during CB) compared to public schools (mean 9.05 (SD 0.91) pre-CB and 9.49 (SD 1.22) hours during CB).
Conclusions
School closure from the COVID-19 pandemic resulted in longer sleep duration in school-going children. Early school/academic activity start times had a significant impact on limiting children’s sleep duration.
Objective
During the outbreak of the COVID-19 pandemic in 2020, high schools closed or transitioned to remote teaching. The aim of this study was to describe how the COVID-19 related school shutdown impacted the sleep behaviors of typically developing adolescents.
Methods
A qualitative study was conducted between April 28 and June 3, 2020 with 45 adolescents using one-on-one semi-structured phone interviews.
Results
The “natural experiment” caused by the shutdown of schools due to the COVID-19 pandemic led to a 2-h shift in the sleep of typically developing adolescents, longer sleep duration, improved sleep quality, and less daytime sleepiness compared to those experienced under the regular school-time schedule.
Discussion
These findings are consistent with previous studies showing that delaying high school start times could be an effective way to extend sleep duration, improve sleep quality, reduce daytime sleepiness and lower adolescents' stress during the school year. As many countries look for ways to reduce the number of interactions between students in schools so that physical distancing is feasible, following teens’ delayed sleep biology could offer an affordable solution. For example, staggering arrival times by delaying school start time for older adolescents compared with younger adolescents can reduce the total number of students attending school at the same time. This strategy offers a practical means to reduce school density and the number of interactions between students which are needed to reduce the potential transmission of COVID-19 in schools, while improving adolescents sleep health.
The American Academy of Pediatrics recommends that U.S. secondary schools begin after 8:30 a.m. to better align with the circadian rhythms of adolescents. Yet due to economic and logistic considerations, the vast majority of high schools begin the school day considerably earlier. We leverage a quasi-natural experiment in which five comprehensive high schools in one of the nation’s largest school systems moved start times forty minutes earlier to better coordinate with earlier-start high schools. Here, disruption effects should exacerbate any harmful consequences. We report on the effect of earlier start times on a broad range of outcomes, including mandatory ACT test scores, absenteeism, on-time progress in high school, and college-going. While we fail to find evidence of harmful effects on test scores, we do see a rise in absenteeism and tardiness rates, as well as higher rates of dropping out of high school. These results suggest that the harmful effects of early start times may not be well captured by considering test scores alone.
Study objectives:
The aim of this study was to examine the association between a 50 minute delay (7:20am to 8:10am) in high school start times in Fairfax County (FC) Virginia (VA) and changes in rates of adolescent motor vehicle crashes. Crash rates in FC were also compared to those in the rest of the state during the same time period.
Methods:
VA Department of Motor Vehicles crash data in 16-18 year old drivers between September and June of each year in FC versus the rest of the state were compared in the combined two year periods preceding (2013-14 and 2014-15; T1) and following (2015-16 and 2016-17; T2) school start time change in the fall of 2015.
Results:
The crash rate per 1000 in 16-18 year old licensed drivers in FC during T1 was significantly higher compared to T2, 31.63 vs 29.59 accidents per 1000 (95% CI, 1.0-1.14, OR 1.07, P=0.03). In contrast, adolescent crash rates in the rest of Virginia were not statistically significantly different at T1 vs T2. With regards to subtypes of crashes, there was a trend towards significance in distraction-related crashes per 1000 in FC at T1 compared to T2 at 7.01 vs 6.13 (95% CI, 0.99-1.31, OR 1.14, P=0.05), but were not significantly different in the remainder of the state.
Conclusions:
The results of this study suggest that school start time delay is associated with decreased adolescent motor vehicle crash risk, with significant implications for public health and safety.
The rapid spread of misinformation online is of growing concern to communication researchers. Scientific misinformation can lead to ill-founded educational practices, health trends, and public policies. In an online survey-based experiment ( N = 744), we corrected neuroscience myths via a mock Facebook newsfeed. We were able to reduce belief in the myths by presenting the subjects with corrective “related articles” immediately following the myth. We also found limited evidence that readers evaluate articles more positively when they are consistent with preexisting views. Our findings are consistent with previous research and extend research on corrective messaging strategies into a new context.
Using a daily diary design and actigraphy sleep data across 2 weeks among 256 ethnic/racial minority adolescents (Mage = 14.72; 40% Asian, 22% Black, 38% Latinx; 2,607 days), this study investigated how previous‐night sleep (duration, quality) moderated the same‐day associations between ethnic/racial discrimination and stress responses (rumination, problem solving, family/peer support seeking) to predict daily well‐being (mood, somatic symptoms, life satisfaction). On days when adolescents experienced greater discrimination, if they slept longer and better the previous night, adolescents engaged in greater active coping (problem solving, peer support seeking), and subsequently had better well‐being. Adolescents also ruminated less when they slept longer the previous night regardless of discrimination. Findings highlight the role of sleep in helping adolescents navigate discrimination by facilitating coping processes.
Disturbances in sleep and circadian rhythms may be important, albeit underappreciated, risk factors for the initiation of alcohol use and the escalation of alcohol problems. In this review, we first describe sleep and circadian changes during adolescence and young adulthood. Second, we explain how these sleep/circadian changes intersect with onset and escalation of alcohol use. Third, we briefly note how alcohol use (whether acute or chronic) affects sleep and circadian rhythms. Finally, we articulate a conceptual model containing two mechanistic pathways-broadly positive and negative reinforcement-linking sleep/circadian factors to alcohol involvement before listing key areas we believe are ripe for further inquiry.
Many U.S. high schools start classes before 8:00 A.M., yet sleep science suggests that students’ circadian rhythms shift to later in the day as they enter adolescence. Some school districts have moved to later start times for high schools based on the prospect that this would increase students’ sleep and academic achievement. This paper examines the effect of high school start time on student learning using a nationally-representative sample of students. We also use time diaries to examine the effects of start time on students’ time allocation in order to explore the mechanisms through which changing start time affects learning. Results indicate that female students who attend schools with later start times get more sleep and score higher on reading tests. Male students get more nighttime sleep when schools start later, but their daily sleep is unchanged due to a decrease in napping; their test scores do not change.
Alcohol use accelerates during late adolescence, predicting the development of alcohol use disorders (AUDs) and other negative outcomes. Identifying modifiable risk factors for alcohol use during this time could lead to novel prevention approaches. Burgeoning evidence suggests that sleep and circadian factors are cross-sectionally and longitudinally linked to alcohol use and problems, but more proximal relationships have been understudied. Circadian misalignment, in particular, is hypothesized to increase the risk for AUDs, but almost no published studies have included a biological measure of misalignment. In the present study, we aimed to extend existing research by assessing the relationship between adolescent circadian misalignment and alcohol use on a proximal timeframe (over two weeks) and by including three complementary measures of circadian alignment. We studied 36 healthy late (18–22 years old, 22 females) alcohol drinkers (reporting ≥1, standard drink per week over the past 30 days) over 14 days. Throughout the study, participants reported prior day’s alcohol use and prior night’s sleep each morning via smartphone and a secure, browser-based interface. Circadian phase was assessed via the dim light melatonin onset (DLMO) in the laboratory on two occasions (Thursday and Sunday nights) in counterbalanced order. The three measures of circadian alignment included DLMO-midsleep interval, “classic” social jet lag (weekday-weekend difference in midsleep), and “objective” social jet lag (weekday-weekend difference in DLMO). Multivariate imputation by chained equations was used to impute missing data, and Poisson regression models were used to assess associations between circadian alignment variables and weekend alcohol use. Covariates included sex, age, Thursday alcohol use, and Thursday sleep characteristics. As predicted, greater misalignment was associated with greater weekend alcohol use for two of the three alignment measures (shorter DLMO-midsleep intervals and larger weekday-weekend differences in midsleep), while larger weekday-weekend differences in DLMO were associated with less alcohol use. Notably, in contrast to expectations, the distribution of weekday-weekend differences in DLMO was nearly equally distributed between individuals advancing over the weekend and those delaying over the weekend. This unexpected finding plausibly reflects the fact that college students are not subject to the same systematically earlier weekday schedules observed in high school students and working adults. These preliminary findings support the need for larger, more definitive studies investigating the proximal relationships between circadian alignment and alcohol use among late adolescents.
Significance
Spreading start times allows school districts to reduce transportation costs by reusing buses between schools. However, assigning each school a time involves both estimating the impact on transportation costs and reconciling additional competing objectives. These challenges force many school districts to make myopic decisions, leading to an expensive and inequitable status quo. For instance, most American teenagers start school before 8:00 AM, despite evidence of significant associated health issues. We propose an algorithm to jointly solve the school bus routing and bell time selection problems. Our application in Boston led to $5 million in yearly savings (maintaining service quality despite a 50-bus fleet reduction) and to the unanimous approval of the first school start time reform in 30 years.
Early school bell times incompatible with adolescent sleep needs and patterns are a major contributor to widespread adolescent sleep insufficiency. Biological delay in sleep onset and social pressures during puberty, combined with the need to arise early on weekdays, make obtaining adequate and optimally timed sleep difficult for most adolescents, potentially impacting physical and emotional wellbeing, safety, and academic performance. Accumulating studies demonstrate that delaying school start times can effectively counter chronic insufficient sleep in adolescents, as well as enhance health, safety, and school success. That many secondary schools continue requiring attendance at times incompatible with healthy sleep suggests that empirical data have played a smaller role in influencing school hours than social and political factors. Overcoming the fear of change, failure of imagination, and ignorance about sleep currently blocking policy changes will require reframing school start times as a public health issue by shifting social norms about sleep.
This report details the 10 leading causes for the 20,360 deaths of children and adolescents in the United States in 2016. The analysis also includes trends over time and comparisons among countries.
Objective:
To determine whether self-reported drowsy driving was associated with an evening chronotype, a biologically-based difference in circadian sleep-wake timing, and shorter school-night sleep duration in a sample of high school drivers.
Study design:
Cross-sectional observational data were obtained from an online survey in spring 2015 of 431 drivers, age 15.5-18.7 years, attending Fairfax County (Virginia) Public schools. Drowsy driving was defined as having ever "driven a car or motor vehicle while feeling drowsy" in the last year. School-night sleep duration was calculated from school-night bedtime and wake time. Those with scores in the lower and upper tertiles of the Morningness-Eveningness Scale for Children were designated as having an evening or morning chronotype, respectively.
Results:
Among survey respondents, 63.1% drove at least several times a week and 47.6% reported drowsy driving. The covariate-adjusted prevalence of drowsy driving was 13.9% (95% CI 3.0%-24.9%) higher in students who slept <7 hours on school-nights than in those who slept 8 or more hours. Compared with those with a morning chronotype, the adjusted prevalence of drowsy driving was 15.2% (95% CI 4.5%-25.9%) higher among those with an evening chronotype.
Conclusion:
Among adolescent drivers, both an evening chronotype and shorter school-night sleep duration were associated with more frequent reports of drowsy driving. Interventions to improve the timing and duration of nighttime sleep in adolescents may reduce the occurrence of drowsy driving.
Youths in America are sleeping less than ever before. More than 70% of high school students average less than 8 hours of sleep,¹ falling short of the 8 to 10 hours that adolescents need for optimal health.² Insufficient sleep negatively affects learning and development and acutely alters judgment, particularly among youths.³ We estimated associations between sleep duration and personal safety risk-taking behaviors in US high school students.
Methods:
This cross-sectional study of 829 adolescents derived sleep duration, efficiency and moderate-to-vigorous physical activity from >5 days of wrist actigraphy recording for >10 hours/day. The main outcome was a metabolic risk score (mean of 5 sex-specific z-scores for waist circumference, systolic blood pressure, high-density lipoprotein cholesterol scaled inversely, and log-transformed triglycerides and homeostatic model assessment of insulin resistance), for which higher scores indicate greater metabolic risk. Secondary outcomes included score components and dual-energy radiograph absorptiometry fat mass. We measured socioeconomic status, race and/or ethnicity, pubertal status, and obesity-related behaviors (television-viewing and fast food and sugar-sweetened beverage consumption) using questionnaires.
Results:
The sample was 51.5% girls; mean (SD) age 13.2 (0.9) years, median (interquartile range) sleep duration was 441.1 (54.8) minutes per day and sleep efficiency was 84.0% (6.3). Longer sleep duration was associated with lower metabolic risk scores (-0.11 points; 95% CI: -0.19 to -0.02, per interquartile range). Associations with sleep efficiency were similar and persisted after adjustment for BMI z score and physical activity, television-viewing, and diet quality. Longer sleep duration and greater sleep efficiency were also favorably associated with waist circumference, systolic blood pressure, high-density lipoprotein cholesterol, and fat mass.
Conclusions:
Longer sleep duration and higher sleep efficiency were associated with a more favorable cardiometabolic profile in early adolescence, independent of other obesity-related behaviors. These results support the need to assess the role of sleep quantity and quality interventions as strategies for improving cardiovascular risk profiles of adolescents.
A rapidly expanding scientific literature supports the frequent co-occurrence of sleep and circadian disturbances following mild traumatic brain injury (mTBI). Although many questions remain unanswered, the preponderance of evidence suggests that sleep and circadian disorders can result from mTBI. Among those with mTBI, sleep disturbances and clinical sleep and circadian disorders contribute to the morbidity and long-term sequelae across domains of functional outcomes and quality of life. Specifically, along with deterioration of neurocognitive performance, insufficient and disturbed sleep can precede, exacerbate, or perpetuate many of the other common sequelae of mTBI, including depression, post-traumatic stress disorder, and chronic pain. Further, sleep and mTBI share neurophysiologic and neuroanatomic mechanisms that likely bear directly on success of rehabilitation following mTBI. For these reasons, focus on disturbed sleep as a modifiable treatment target has high likelihood of improving outcomes in mTBI. Here, we review relevant literature and present a research agenda to 1) advance understanding of the reciprocal relationships between sleep and circadian factors and mTBI sequelae and 2) advance rapidly the development of sleep-related treatments in this population.
Communicating scientific uncertainty about public health threats is ethically desirable but challenging due to its tendency to promote avoidance of choice options with unknown probabilities—a phenomenon known as “ambiguity aversion.” This study examined this phenomenon’s potential magnitude, its responses to different communication strategies, and its mechanisms. In a factorial experiment, 2701 adult laypersons in Spain read one of three versions of a hypothetical newspaper article describing a pandemic vaccine-preventable disease (VPD), but varying in scientific uncertainty about VPD risk and vaccine effectiveness: No-Uncertainty, Uncertainty, and Normalized-Uncertainty (emphasizing its expected nature). Vaccination intentions were lower for the Uncertainty and Normalized-Uncertainty groups compared to the No-Uncertainty group, consistent with ambiguity aversion; Uncertainty and Normalized-Uncertainty groups did not differ. Ambiguity-averse responses were moderated by health literacy and mediated by perceptions of vaccine effectiveness, VPD likelihood, and VPD severity. Communicating scientific uncertainty about public health threats warrants caution and further research to elucidate its outcomes, mechanisms, and management.
A growing body of literature suggests a critical implication of sleep in emotional processing. This review aims at synthesizing current evidence on the role of sleep and sleep loss in the modulation of emotional reactivity, emotional memory formation, empathic behavior, fear conditioning, threat generalization and extinction memory. Behavioral and neurophysiological evidence suggesting a preferential implication of rapid-eye movement (REM) sleep in emotional processing is also discussed. Furthermore, we examine the relations between sleep and emotions by overviewing the functional neuroimaging studies that elucidated the brain mechanisms underlying these relations. It is shown that sleep supports the formation of emotional episodic memories throughout all the stages that compose memory processing. On the contrary, as sleep loss deteriorates the encoding of emotional information, as it leads to a disruptive interference with emotional memory consolidation.
Research is also progressively providing new insights into the protective role of sleep on human emotional homeostasis and emotional regulation, promoting an adaptive next-day emotional reactivity. In this respect, evidences converge in indicating that lack of sleep significantly influences emotional reactivity. Moreover, notwithstanding some contradictory findings, the processing of emotionally salient information could mainly benefit from REM sleep. However, some crucial aspects of the sleep-dependent emotional modulation remain unclear. Further clarifying how sleep affects emotional brain functioning will be an important issue for future investigations, with relevant implications for clinical settings.