It has been clearly documented in the pediatric and sleep medicine literature that teenagers are chronically sleep deprived. In August 2014, the American Academy of Pediatrics (AAP) published a Policy Statement regarding School Start Times for Adolescence.1 The AAP has recognized insufficient sleep in adolescence as an important public health issue that significantly affects health and safety of our teens. Insufficient sleep is one of the most common, important, and potentially remediable health risks in teens (as well as all children).2
There appears to be a significant lack of awareness among children, adolescents, young adults, and adults of the extent of sleep loss during the middle and high school-aged youngsters as well as society in general.3 Sleep seems to be as important to health and well-being as food. Significant adverse effects occur when there is cumulative sleep loss. It has been recommended that school administrators initiate district-wide assessments on school start times, varying scheduling options, decreasing nightly homework hours, and instituting sleep education programs into their curriculum.4 It is also been suggested that healthcare providers can initiate positive behavior changes by educating adolescents and parents about sleep needs and by serving as ambassadors in their communities.5
As stated by Blunden and Rigney6 in this issue of Journal of Clinical Sleep Medicine, there is a paucity of quantity, quality, and effectiveness; as well as methodology within literature regarding school-based sleep education programs. As was stated in their study rationale: “…sleep health is the foundation to general physical and mental health, sleep education programs and to improve the sleep health of young people.” They point out, there are currently only 11 worldwide published studies of sleep education programs focused on adolescents and 2 papers in press. The authors review these studies and identify the scope, aims, and effectiveness of these programs. Educational programs fell into 2 categories: one to disseminate information and improve knowledge base regarding sleep, and the second intended to change sleep behavior. Difficulty in both areas is clear from their review and report. Programs vary according to method of delivery, status and ability of the presenter, as well as outcome measures and tools. Indeed, sleep education at all levels of education has a long way to go and many obstacles to overcome. First, just by increasing knowledge base does not necessarily change behavior. Can we take lessons from educational programs focused on obesity7 and hazards of tobacco use? Educational programs are common; some are effective and others are not.8 Nonetheless, there appears to be a continued obesity epidemic that has not been stemmed by improved knowledge of nutrition, and people continue to smoke. Suggestions are provided to improve both knowledge and behavioral interventions.
Perhaps focusing on how seat belt usage increased over the past half-century might provide a basis for the multifactorial influences on knowledge and behavior. Original public health initiatives in improving knowledge of seat belt use resulted in limited success.9,10 Behavior change only occurred when there was a concerted societal effort by changing laws, manufacturing all automobiles with seat belts, providing warning systems when belts were not engaged, and limiting the ability to start or drive the automobile without the belt being engaged. Nevertheless, people still figured out ways to circumvent use. Significant change occurred when there was a combination of enacted laws, and subliminal messages became pervasive. Heroes on television and in movies automatically put on their seat belts without comment or focus on the educational component whenever they entered a car. Parents used their seat belts and required children to do the same. This subliminal message of role models performing specific behaviors is a very powerful tool. A “stealth curriculum” may add to Blunden and Rigney's suggestion that a problem-based approach be incorporated into a multidisciplinary educational model. This model would include sleep education in every course and throughout the day. For example, attention to sleep may be placed into math classes by teaching addition by using hours of sleep, added to science classes with focus on circadian rhythms of plants and animals, reading and literature classes by adding discussion of sleep of characters in stories being studied. Art classes can use a plethora of images relating to sleep to begin discussion of art appreciation. Sleep education can also be included in subjects as widely varied as physical education and computer science. Indeed, the authors have suggested engaging students in novel ways using consumer electronics and apps that can be accessed by young and old. Other inexpensive interventions to improve sleepiness during adolescence might be instituted immediately. These include but are not limited to changing school start times,1 bright lights in school classrooms, nap rooms, scheduling difficult courses such as math and sciences in the late morning or afternoon, and scheduling testing in the afternoons.
There are few answers gleaned from this paper. Nonetheless, it is a very important paper since it provides eye-opening insight into the status of sleep education in schools and standing of knowledge of normal sleep development in children and adolescents. Data presented by Blunden and Rigney clearly elucidate sleep education of adolescents and the public in general is dismal. This paper appears to be an awakening for the sleep medicine community to take action not only by providing educational programs to patients, public, legislators, and educators; but also a challenge to the sleep medicine community to begin fundamental educational research in methods that can result in long-lasting change in sleep knowledge and ultimately behavior during childhood and adolescence.
The authors have indicated no financial conflicts of interest.
Sheldon SH. Sleep education in schools: where do we stand? J Clin Sleep Med 2015;11(6):595–596.
Adolescent Sleep Working Group and Committee on Adolescence, and Council on School Health. Policy Statement: School Start Times for Adolescents. Pediatrics. 2014;134:642–9. [PubMed]
Chen MY, Wang EK, Jeng YJ, authors. Adequate sleep among adolescence is positively associated with health status and health-related behaviors. BMC Public Health. 2006;6:59. [PubMed Central][PubMed]
Wolfson AR, Johnson M, authors. Sleep and school start times. In: Sheldon SH, Ferber R, Kryger MH, Gozal D, editors. Principles and practice of pediatric sleep medicine. 2nd ed. Elsevier Health Sciences, 2014:389–95.
Carskadon MA, Wolfson AR, Acebo C, et al., authors. adolescent sleep patterns, circadian timing, and sleepiness at a transition to early school days. Sleep. 1998;21:871–81. [PubMed]
Davison CM, Newton L, Brown RS, et al., authors. Systematic review protocol: later school start times for supporting the education, health, and well-being of high school students. Cochrane Collaboration, 2011.
Blunden S, Rigney G, authors. Lessons learned from sleep education in schools: a review of dos and don'ts. J Clin Sleep Med. 2015;11:671–80.
Natale RA, Messiah SE, Asfour L, Uhlhorn SB, Delamater A, Arheart KL, authors. Role modeling as an early childhood obesity prevention strategy: effect of parents and teachers on preschool children's healthy lifestyle habits. J Dev Behav Pediatr. 2014;35:378–87. [PubMed]
Beauchamp A, Backholer K, Magliano D, Peeters A, authors. the effect of obesity prevention interventions according to socioeconomic position: a systematic review. Obes Rev. 2014;15:541–54. [PubMed]
Wermert AM, Mehl A, Opalek JM, Shaffer LE, authors. Implementation an early outcomes of a peer-led traffic safety initiative for high school students. J Trauma Nurs. 2012;19:94–101. [PubMed]
Yanchar NL, Kirkland SA, LeBlanc JC, Langille DB, authors. Discrepancies between knowledge and practice of childhood motor vehicle occupant safety in Nova Scotia-a population-based study. Accid Anal Prev. 2012;45:326–33. [PubMed]