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Children's Sleep: Time For A Wake-Up Call

Except for a handful of forward-thinking school districts, the continuing resistance to starting high school later to accommodate the biological time clocks of teenagers speaks to the attitudes of the adults in charge of our children.
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Except for a handful of forward-thinking school districts, the continuing resistance to starting high school later to accommodate the biological time clocks of teenagers speaks to the attitudes of the adults in charge of our children. How can it be that despite overwhelming evidence that sleep deprivation in teenagers is every bit the public health menace that cigarette smoking is, school administrators have abided the status quo?

Sleep researchers have convincingly demonstrated that, on average, teenagers need nine hours of sleep and that their brains are programmed for them to stay up later than adults. Sleep researchers have also convincingly demonstrated that, on average, adults need eight hours of sleep. Not getting enough sleep is as pervasive in today's culture as was consuming two or three packs per day of Lucky Strikes in the 1940s, 50s and 60s.

In reaction to a July 2010 Wall Street Journal article reporting the salutary effects of starting first period later at a Rhode Island prep school, several commenters decried what they termed the coddling of a generation and giving in to spoiled brats' laziness -- precisely how depression was depicted four decades ago -- rather than responding to a biological imperative. School boards and superintendents, whose reputation and ranking depend on how many advanced-placement tests their students pass, have not come to grips with the toll that sleep deprivation takes on the developing adolescent brain.

Sleep is essential for sustained focus, concentration, and attention, the brain circuitry of which is the same in children and adolescents as it is in adults. The prefrontal cortex, center of complex reasoning, signals the striatum, a deeper brain structure which modulates activity and attention to novel stimuli, which connects to an even deeper area called the thalamus, which relays sensory input from the body and regulates alertness and sleep. Sustained attention requires that these three brain structures, known as the CST system, cooperate, a function of the brain neurotransmitters norepinephrine and dopamine. Sleep deprivation not only reduces CST function, it alters CST norepinephrine and dopamine levels. Amphetamines, the mainstay of treatment for inattention, stimulate CST circuitry artificially by either mimicking dopamine at nerve cell endings or stimulating dopamine's release. However, clinical experience shows that amphetamines interfere with sleep and in excess act like cocaine, which can overexcite nerve cells to the point they self-destruct. Prolonged amphetamine abuse can produce a syndrome that looks like schizophrenia.

Clinically, every psychiatric disorder I treat in adolescents is worsened by getting too little sleep. Well over half the teenagers who come to me with attention symptoms are sleep deprived. While CST malfunction is not caused by sleep deprivation alone, and amphetamines have a role in medicine's pharmacopeia, my experience is that medicating the inattentiveness and cognitive impairment of sleep-deprived youngsters with amphetamines -- teenagers today bum Adderall from each other like cigarettes -- is like trying to paralyze the tail that wags the dog, or like treating a smoker's hacking with codeine-containing cough suppressants while failing to address the lung disease.

What's at issue here is an attitude change with respect to sleep behavior. Change is hard. Change requires self-reflection; there is no way around it. Facing sleep deprivation head-on means that the adults in charge of our teenagers acknowledge and deal with their own sleeping habits, including maladaptive sleep behaviors like the widespread use and abuse of sleeping pills and alcohol at bedtime; like stimulant and caffeine dependence and abuse during the day; like snoring and obstructive sleep apnea and the toll snoring takes on sleep-partners and relationships; like arguing at bedtime, as well as a host of unattended mental and physical disorders -- depression, obesity and diabetes for instance -- that disrupt sleep patterns.

Years ago, senior physicians rationalized the hundred-plus hour work weeks they demanded of their bleary-eyed trainees saying, "Four hours of sleep were good enough for me." Now that we know how many preventable mistakes were caused by secondhand sleep deprivation, medical trainee's work-weeks have been scaled back to no more than eighty hours.

I am not advocating we lower academic standards; far from it. However, as a physician who cares deeply about the health and welfare of teenagers, I feel it is essential we give adolescents the opportunity to get the sleep needed for optimal brain function. These are the facts: well-rested adolescents significantly outperform their sleep-deprived counterparts academically; their moods are better; their graduation rates are higher; they watch less television; they do more homework; and they are involved in fewer car crashes.

High school should start at 8:45 a.m., or better at 9 o'clock. The successful grassroots campaign of Wilton, Connecticut's League of Women voters, which moved their high school start time 50 minutes later, proves that logistical complications like busing schedules and after school activities, often cited as obstacles to change, can be overcome when the community is involved and motivated.

It's only a matter of time until the family of someone killed when a teenager falls asleep at the wheel brings action for reckless endangerment. School board members and superintendents need to wake up now, before they receive the subpoena.

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