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Volume 13 No. 05
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Accepted Papers

Letters to the Editor

Commentary on Healthy School Start Times

Judith Owens, MD, MPH1; Wendy Troxel, PhD2; Kyla Wahlstrom, PhD3
1Harvard Medical School, Boston, Massachusetts; 2RAND Corporation, Santa Monica, California; 3University of Minnesota, Minneapolis, Minnesota

As sleep scientists and public health policy experts with considerable expertise regarding the topic of healthy school start times for middle and high school students, we are writing to express concerns regarding the recent review that was published in the Journal of Clinical Sleep Medicine, “High School Start Times and the Impact on High School Students: What We Know, and What We Hope to Learn.”1 Given the current intense interest in this topic from a range of audiences, including school administrators, policy makers, and the public, we are concerned about language in the report that refers to the overall evidence as “weak or very weak.” Such statements are likely to be quoted without the context of the full report, and without understanding the methodological criteria applied to make such a determination. As districts across the country grapple with logistical and other issues concomitant with school start time changes, we wish to make the following points in the interest of adolescent health.

First, we take issue with the decision to exclude the substantial body of peer-reviewed literature published in major educational journals (eg, Educational Researcher) on the topic of school start times. Given that start times is ultimately an issue of education policy, we believe that the omission of these studies and failure to specifically search education databases is tantamount to “telling only half the story.”

Second, although not explicitly stated what system was used to judge the quality of the evidence, increasing concerns have been raised about the appropriateness of using criteria designed primarily for medical interventions (eg, GRADE) for evaluating complex social interventions.2 Because school start time change is an educational policy decision, not a medical intervention, it is likely that research in this area will never receive “high” or “strong” ratings based on traditional criteria, especially given the complexity of school environments, and the infeasibility of randomizing students or school districts to different start times.

Furthermore, labeling the evidence “weak or very weak” has the potential to dissuade decision makers and policy makers from even initiating a dialogue about start time change, despite the fact that the best available evidence shows that this intervention could have powerful and sustained benefits for adolescent health, well-being, and public safety. The acknowledged impact on driving accidents alone, given that accidental injuries including car crashes are the number one cause of mortality in American adolescents, should be more than sufficient justification to support a policy change that could potentially save lives.

We acknowledging that more research is both needed and welcome, but at this juncture what is required are strong public statements from the sleep community about healthy school start times (similar to those expressed by the American Academy of Pediatrics3). These statements should accurately reflect the current data in the context of the practical limitations involved in conducting this research and simultaneously address the urgency of the issue. It is ultimately our contention that given the available evidence on the benefits of school start time change, “to do nothing is to do harm.”


The authors have indicated no financial conflicts of interest.


Owens J, Troxel W, Wahlstrom K. Commentary on healthy school start times. J Clin Sleep Med. 2017;13(5):761.



Morgenthaler TI, Hashmi S, Croft JB, Dort L, Heald JL, Mullington J. High school start times and the impact on high school students: what we know, and what we hope to learn. J Clin Sleep Med. 2016;12(12):1681–1689. [PubMed]


Rychetnik L, Frommer M, Hawe P, Shiell A. Criteria for evaluating evidence on public health interventions. J Epidemiol Community Health. 2002;56(2):119–127. [PubMed Central][PubMed]


Adolescent Sleep Working Group, Committee on Adolescence, and Council on School Health. School start times for adolescents. Pediatrics. 2014;134(3):642–649. [PubMed]