Study 1

Abstract
Study objectives:

To assess the effects of delayed high-school start times on sleep and motor vehicle
crashes.
Methods:

The sleep habits and motor vehicle crash rates of adolescents from a single, large,
county-wide, school district were assessed by questionnaire before and after a 1-hour
delay in school start times.
Results:

Average hours of nightly sleep increased and catch-up sleep on weekends decreased.
Average crash rates for teen drivers in the study county in the 2 years after the change
in school start time dropped 16.5%, compared with the 2 years prior to the change,
whereas teen crash rates for the rest of the state increased 7.8% over the same time
period.
Conclusions:

Later school start times may both increase the sleep of adolescents and decrease their
risk of motor vehicle crashes.
Citation:

Danner F; Phillips B. Adolescent sleep, school start times, and teen motor vehicle
crashes. J Clin Sleep Med 2008;4(6):533535.

Study 2
Abstract
Study Objectives:

Early high school start times may contribute to insufficient sleep leading to increased
teen crash rate. Virginia Beach (VB) and Chesapeake are adjacent, demographically
similar cities. VB high schools start 75-80 minutes earlier than Chesapeake's. We
hypothesized that VB teens would manifest a higher crash rate than Chesapeake teens.
Methods:

The Virginia Department of Motor Vehicles (DMV) provided de-identified, aggregate

2008 and 2007 data for weekday crashes and crash times in VB and Chesapeake for
drivers aged 16-18 years (teens), and provided 2008 and 2007 crash data for all
drivers. Data allowed comparisons of VB versus Chesapeake crash rates for teens
(overall and hour-by-hour), and teens versus all other ages. We compared AM and PM
traffic congestion (peak hours) in the two cities.
Results:

In 2008, there were 12,916 and 8,459 Virginia Beach and Chesapeake 16- to 18-yearold drivers, respectively. For VB and Chesapeake, teen drivers' crash rates in 2008
were 65.8/1000 and 46.6/1000 (p < 0.001), respectively, and in 2007 were 71.2/1000
and 55.6/1000. Teen drivers' crash peaks in the morning occurred one hour earlier in VB
than Chesapeake, consistent with school commute time. Congestion data for VB and
Chesapeake did not explain the different crash rates.
Conclusions:

A significantly increased teen crash rate for both 2008 and 2007 occurred in VB, the city
with earlier high school start times. Future studies using individual level data may clarify
if sleep restriction, circadian dyssynchrony, and sleep inertia might contribute to this
increased crash rate.
Citation:

Vorona RD; Szklo-Coxe M; Wu A; Dubik M; Zhao Y; Ware JC. Dissimilar teen crash
rates in two neighboring southeastern Virginia cities with different high school start
times. J Clin Sleep Med2011;7(2):145-151.

Study 3
Abstract
IMPORTANCE:
Short sleep duration is common in adolescents and young adults, and short sleep duration is a risk factor
for motor vehicle crash.
OBJECTIVE:
To assess the association between hours of sleep and the risk for motor vehicle crash, including the time
of day of crash and types of crash (single, multiple vehicle, run off road, and intersection).
DESIGN:
Prospective cohort study.
SETTING:
New South Wales, Australia.
PARTICIPANTS:
Questionnaire responses were obtained from 20,822 newly licensed drivers aged 17 to 24 years.
Participants held a first-stage provisional license between June 2003 and December 2004 prospectively
linked to licensing and police-reported crash data, with an average of 2 years of follow-up. Analyses were
conducted on a subsample of 19,327 participants for which there was full information.
EXPOSURE:
Sleeping 6 or fewer hours per night.
MAIN OUTCOMES AND MEASURES:
The main outcome variable was police-reported crash. Multivariable Poisson regression models were
used to investigate the role of sleep duration on the risk for crash.
RESULTS:
On average, those who reported sleeping 6 or fewer hours per night had an increased risk for crash
compared with those who reported sleeping more than 6 hours (relative risk [RR], 1.21; 95% CI, 1.041.41). Less weekend sleep was significantly associated with an increased risk for run-off-road crashes
(RR, 1.55; 95% CI, 1.21-2.00). Crashes for individuals who had less sleep per night (on average and on
weekends) were significantly more likely to occur between 8 pm and 6 am (RR, 1.86; 95% CI, 1.11-3.13,
for midnight to 5:59 am and RR, 1.66; 95% CI, 1.15-2.39, for 8:00 pm to 11:59 pm).

CONCLUSIONS AND RELEVANCE:

Less sleep per night significantly increased the risk for crash for young drivers. Less sleep on weekend
nights increased the risk for run-off-road crashes and crashes occurring in the late-night hours. This
provides rationale for governments and health care providers to address sleep-related crashes among
young drivers.

Study 4
ABSTRACT: Adolescent development is accompanied by profound changes in the timing
and amounts of sleep and wakefulness. Many aspects of these changes result from
altered psychosocial and life-style circumstances that accompany adolescence. The
maturation of biological processes regulating sleep/wake systems, however, may be
strongly related to the sleep timing and amount during adolescenceeither as
compelling or permissive factors. The two-process model of sleep regulation posits a
fundamental sleep-wake homeostatic process (process S) working in concert with the
circadian biological timing system (process C) as the primary intrinsic regulatory factors.
How do these systems change during adolescence? We present data from adolescent
participants examining EEG markers of sleep homeostasis to evaluate whether process
S shows maturational changes permissive of altered sleep patterns across puberty. Our
data indicate that certain aspects of the homeostatic system are unchanged from late
childhood to young adulthood, while other features change in a manner that is
permissive of later bedtimes in older adolescents. We also show alterations of the
circadian timing system indicating a possible circadian substrate for later adolescent
sleep timing. The circadian parameters we have assessed include phase, period,
melatonin secretory pattern, light sensitivity, and phase relationships, all of which show
evidence of changes during pubertal development with potential to alter sleep patterns
substantially. However the changes are mediatedwhether through process S, process
C, or by a combinationmany adolescents have too little sleep at the wrong circadian
phase. This pattern is associated with increased risks for excessive sleepiness, difficulty
with mood regulation, impaired academic performance, learning difficulties, school
tardiness and absenteeism, and accidents and injuries.

Study 5
Objective. To survey caffeine use by seventh-, eighth-, and ninth-graders
and relate its use to age, sex, sleep characteristics, and day of week
Methods. Students kept a daily, 2-week diary of their sleep times and use
of caffeine containing drinks and foods. Data were analyzed by fitted
multiple regression models
Results. A total of 191 students participated. Caffeine intake ranged
between 0 and 800 mg/d. Mean use over 2 weeks ranged up to 379.4 mg/d
and averaged 62.7 mg/d (corrected for underrepresentation in our sample
of boys, who consumed more caffeine). Higher caffeine intake in general
was associated with shorter nocturnal sleep duration, increased wake time
after sleep onset, and increased daytime sleep
Sleep Patterns. Mean bedtime was 10:57 PM, and mean wake time was at
7:14AM. Older children delayed bedtime longer on weekends, and younger
ones had longer nightly sleep durations. Sleep duration lengthened on
weekends, reflecting the combined effects of the circadian timing system
and a mechanism that regulates the duration of sleep. Caffeine (soda)
consumption also increased on weekends, for reasons that may be
primarily social
Conclusions. Regardless of whether caffeine use disturbed sleep or was
consumed to counteract the daytime effect of interrupted sleep, caffeinated
beverages had detectable pharmacologic effects. Limitation of the
availability of caffeine to teenagers should therefore be considered.

Situation 1
The Principal of James Woods High School has recently become fed
up with traffic on his daily commute. In order to avoid the traffic he has
proposed a new plan to move the starting time of his school to 6:00 AM.
This would allow school staff to drive on empty roads in the morning and
slightly less busy roads on the way home. He believes that this will make
the commute safer for students and staff.

a) Do you think this is a good idea?

b) Do you think that he is right that it would make the commute safer for
students and staff? Why or why not?

c) After reading about these sleep studies, how would you respond to
the Principal of James Woods High School? Please include an
alternative to the suggested plan.

Situation 2
Teachers at Summer Heights High have recently seen a dip in test
scores. To remedy this, the school has implemented mandatory morning
tutoring sessions for any student below a B average. These tutoring
sessions take place before school starts and aim to improve these
struggling students grades. One teacher has suggested that the sessions
be moved to after school, but was quickly dismissed.

a) Do you think early morning tutoring sessions are a good idea to help
struggling students?

b) Do you think they will help students to get their grades up?

c) After reading about these sleep studies how would you respond to
the teachers at Summer Heights High who want to implement
mandatory morning tutoring for struggling students? Please include
an alternative to the suggested plan.

Situation 3
The Assistant Principal at Bayside High School has become fed up
with behavior issues in the school.
Problems have included sleeping
in class, chronic tardiness, widespread absenteeism, and violent outbursts.
Because of all of the detentions being given out he has had to create a
second detention period before the original. The schedule now goes,
Detention hour one:6:00-6:45, detention hour one:6:45-7:30. School starts
just after these two detention periods at 7:45.

a)Do you think an extra early detention period is a good idea?

b)

Do you think the extra early detention period will help solve the
behavior problems at Bayside HS?

c)Using what you have learned from the sleep studies, respond to the
AP of Bayside HS. Please include an alternative to the suggested
plan.

Situation 4
Administrators at Arlen High School have noticed a problem recently
with students being overly tired during class. In order to remedy this the
school has ordered 6 new cappuccino machines and replaced the drinking
fountains with red bull dispensers. Administrators believe this will keep
students awake and help them stay alert during class.

a) Do you think this is a good idea?

b) Do you think increasing students caffeine intake will solve the

problems the high school is having with students staying awake
through the day?

c) Using the information from the studies you have read come up with a
response to the administrators plan. Please include an alternative to
the suggested plan.

Situation 5
East Great Falls has recently had problems with students getting into
car accidents before and after school. The administrators have blamed this
on recklessness and adolescent negligence. In order to encourage
students to drive more safely they have added punishments for anyone
involved in a car accident. Students who are involved in car accidents now
have to come in for a driving safety course before school.

a)Do you think this is a good idea?

b) Do you think this will result in fewer or more car crashes?

c) Using the studies you have read respond to the administrators plan. Please
include an alternative to the plan suggested.

Situation 6
Administrators at Ridgemont High School have noticed problems recently with
students getting into car accidents before school. They have come up with a plan they
believe will help to reduce the number of car accidents. Their plan is to move the start
of the day back one hour so that school will now begin at 6:25. This will mean the
students will have less traffic to worry about while driving and will have a lower chance
of getting into an accident.

a) Do you think this is a good idea?

b) Do you think this would result in fewer accidents?

c) Using the studies you have read respond to the administrators plan. Please
include an alternative to the plan suggested.