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>>WOLFSON: All right, thank you very much, Nancy. I'm so glad to be here. I'm known for
having way too much material. That's not my strength as a teacher. So hopefully, I may
bust through a few slides and not cover absolutely everything that I can on covering.
This is going to be a real sort of mixture of ideas and thoughts and material for you
this morning. I wanted to both give you a sense of what's known today, science-wise,
behavioral science-wise in terms sleep and adolescence, but I also wanted to give you
a flavor for some of the things that I do with my students when I'm teaching, both specifically
with regard to adolescence and sleep but more broadly sleep. I teach undergraduate course
specifically on it's called sleep and behavior, and so I'm sort of going to dabble a little
bit in some of the things I do in that course as well as the science and what I would be
doing if I were speaking to you to just share some of my research. It's going to be a real
mixture. Bear with me because we'll do ... so we're going to go back and forth. I'm also
going to get you kind of moving around or in some small groups before we finish up this
morning. All that in 90 minutes, we will see how that works.
For starters, what I'd love for you to do is one of the handouts ... I'm rather old-fashioned.
I just yesterday was in an iPad workshop and yet I'm still kind of paper and pencil and
I hand things out. If you could take the sleep quiz, take just a couple of minutes to fill
that out, and this is something you can take and adapt for your own purposes with your
high school students. I've been using these questions for years. I won't answer all. We
won't go through all of them, but after you do it, we're going to just go through a couple
of them. And the one handout I have not given you are the answers, so you can take that
on your way out. So if you could just take a couple of minutes to fill that out, the
sleep quiz. [Pause]
You should be done by now. So I want to go through a couple of them, and this is really
to get you thinking about sleep and circadian rhythms. So let's just take a look at the
very first question. Students fall asleep in classes because professors, because teachers
are boring. True or false, and what's your explanation for your answer? Why is that false?
Yes? Just say your first name just so I ... yeah.
>>WORKSHOP PARTICIPANT: [Unclear] politics say that professors are boring and that's
why students are falling asleep.
>>WOLFSON: All right. But what's the scientific or what's the explanation for why this ...
>>WORKSHOP PARTICIPANT: There could be many other factors involved in why they're falling
asleep.
>>WOLFSON: Okay. Can someone say any specific about sleep just in terms of your knowledge
about sleep? Yeah?
>>WORKSHOP PARTICIPANT: It depends on what time of day it is.
>>WOLFSON: Well, so it could be time of day, absolutely, but ... yeah?
>>WORKSHOP PARTICIPANT: It could be the lack of sleep that's going to just make you ... and
you're just going to be ...
>>WOLFSON: Exactly. I mean, I realize that we're talking here about teaching psychology
courses, but we have a biological drive to sleep. We can only stay awake so long and
we are going to fall sleep. Now, it's true, time of day, I mean certainly teaching adolescents,
those of you who teach in high schools that start before 8:30 or so in the morning are
going to have the experience of having students, if you teach first or even second period classes,
who may be sleepy relating to the time of day or getting an inadequate amount to sleep
the night before. Those of you who have students sometimes around the lunch period may find
that students are sleepy for other reasons. So there is time of day can be a factor.
Also, lighting can be a factor. So not you personally, not your teaching style necessarily,
but if you teach at 7:30 in the morning and you show a film in your AP psychology class
and you put all the lights off, I don't care how exciting the film is, you may have a higher
percentage of students who don't see the film, so to speak. But by and large, if you have
... I think that the main point that I want to make with this in terms of really your
teaching experience, not just the knowledge, is that if you have a student class after
class who falls asleep, that's a student that you need to draw attention to. That's the
student that you should be talking to that student. That's a student who you should be
bringing to the school nurse's attention and so on. That would not be sort of within normal
range, to do that day after day after day. That's not my focus for today, but I'm happy
to answer questions about that later on.
I'm going to talk a lot about question three in a couple of minutes, so we won't talk about
that one, but let's see. How about question five? Effects of sleep loss add up over the
course of several nights and days, true or false?
>>WORKSHOP PARTICIPANT: True.
>>WOLFSON: Okay, so that's absolutely true. Can someone say anything about that? Yeah?
>>WORKSHOP PARTICIPANT: We accumulate what's called sleep debt.
>>WOLFSON: Exactly. Exactly. Now, you can do something about it. I mean just assume
that you can. We can't make up for it. We accumulate our sleep loss unfortunately with
our modern 24/7 lives or more than 24/7 lives no matter what. But we can make up for some
sleep loss in the sense that we can sleep more on the weekends, and teenagers unfortunately
do what we call binge sleeping, which is problematic and then causes other difficulties.
Also, being on an erratic schedule, whether we're an adolescent or an adult is problematic,
and so too much of that sleeping, say, on one schedule during the week and another schedule
on weekends is problematic. And most of the research suggest, particularly with adolescents,
that more than a 90-minute, some research says only a 60-minute difference in the timing
of your sleep, that irregular or erratic schedule can have negative implications. So, when we're
looking at sleep, we're not just looking at sleep duration, but we're always looking at
other sleep-wake variables, and we can talk more about that.
Number nine, over 100,000 car accidents yearly are related to sleepiness, true or false?
It's true, and it's probably closer to 200,000 to tell you the truth. And adolescents, particularly
male adolescents as well as college-age students are the age group that is at greatest risk
to fall asleep at the wheel, motor vehicle accidents, and that's without alcohol. When
you combine alcohol in the case, there's actually a synergistic effect that puts you even at
greater risk.
One of the nightmare kinds of stories that you read about is a college student who at,
say, Thanksgiving break and you go to college in Worcester, Massachusetts but your family
lives in Virginia, and your parents have put great pressure on you to get home for Thanksgiving.
Classes end but you want to socialize with your friends, so you stay on the college campus,
if it's a campus that allows you to do this. And then you get on the road, say, if it's
Tuesday or Wednesday, regardless of the day, and you don't leave campus until 9:00 in the
evening, and then you head home to get to the D.C. area.
High-risk situation for two reasons: that individual is sleep-deprived; that individual
may have been drinking, but even without the alcohol, sleep-deprived. And then the time
of day, and we'll talk about circadian rhythms in a couple of minutes, but the time of day
if you picture sort of that eight-hour or nine-hour drive, they may be getting into
the D.C. area in the dawn hours, and the drive to sleep in terms of where our circadian clock
is, is the greatest in those early dawn hours. So that's a very sleepy time similar to the
actual natural time that we're more likely to be ready to go to sleep. That's another
high-risk period of time. So there's a combination - I'm going to talk about this in a couple
of minutes - of what we call sleep pressure or homeostatic sleep pressure and our circadian
timing. That sort of creates this awful situation at that time. So it isn't just sleep deprivation.
What's that?
>>WORKSHOP PARTICIPANT: "I did everything," she said, "but I wasn't dreaming." And I get
a telephone call. So I drove through a traffic light sound asleep. An intersection, I hit
a traffic pole in front of the bank, in front of the apartment, so I was on my way home.
So I was right in front of my apartment when it happened.
>>WOLFSON: Yeah, that's not uncommon.
>>WORKSHOP PARTICIPANT: Yeah, very scary.
>>WOLFSON: So something to think about. Number 11: caffeinated sodas, coffee, hot chocolate,
and other sources of caffeine can help keep you awake, true or false? A pretty simple
question if you first look at it. Okay. You'd be surprise the number of adults, I'm sure
we've all been in this situation where you have a lovely evening together with some friends;
you've had a couple of drinks. Dessert time comes around and your host or hostess says,
would you like caffeinated or decaf, and a number of people say, oh, I want some caffeine.
It doesn't bother me. I don't notice that I stay awake having caffeine. Caffeine is
a stimulant. And the only reason I bring this up with regard to your working with high school
students and adolescent sleep, it's really a new area of research. Actually, I'm doing
some work in this area myself.
There's some suggestion that high caffeine use or caffeine use in adolescence or in late
childhood may be an entry drug. My colleague, Alison Ludden, at Holy Cross is doing some
work in this area. I don't have to tell you that the number of adolescents, the growing
number of adolescents ... and I have a couple of slides about this, and I could have done
a whole morning just talking about stimulants and sleep and adolescent development as well,
but I do think it's something that you need to be beginning to cover and to talk about,
and I'd be happy to talk more about that. But we're in a Red Bull culture, unfortunately.
And I don't think ... I guess what I will say is I don't think it's coincidental that
the attention, the wave of attention that is now, thankfully, in my opinion, sort of
have been covered by the media with regard to sleep deprivation, both broadly in terms
of the general population but specifically adolescence and college students, and at the
same time we have had a growth in the caffeine industry.
I was just in Starbucks now ... I should have brought the packets. Actually, I kind of like
it. But it has this new ... you go in to most Starbucks this summer - has anyone seen this
- and they're selling these two types of drinks. You can get one that's like a berry flavor
and one that's a lime flavor. And it is not limeade. It is lime flavored but the actual
product is, are the raw coffee beans that are being used to make this beverage so there's
caffeine in it. And the signs are like: refreshing, come in for the summer, refresh, you know.
And you can buy them powder now. And you would not know it has caffeine unless you read the
fine lines. In other words, it's not even being marketed as a caffeine drink. It's being
marketed as a new way of using coffee beans. So go figure. The teenagers will be drinking
that soon as well.
I'm not going to do any more of these questions, but this is a lot of fun. I often start, if
it's a unit relating to sleep, say I'm teaching a course on abnormal psych or intro psych
or in my upper level sleep course, it's a great way to just start a conversation on
the topics using this approach. I don't have to tell you that, but these are some of the
questions.
I'm not going to go over all the handouts I've given you, but I just wanted to sort
of give you a couple of samplings of the kinds of things that will be fun or useful in the
classroom with high school students.
I've given you a sleep-wake diary. This is mine. I've actually used this in an NIH-funded
study with middle school students, and this is a sample. You're welcome to make use of
it in any way that you'd like. But it's fun sometimes to have your students complete a
sleep-wake diary, say, for a week. And even with my college students, I will have them
complete a sleep-wake diary for a week and then write a short kind of paper analysis
of the data. It's a fun way. I'm sure you've come up with different ways that you get students
to understand data collection, but a sleep-wake diary works great because you can have students
both pay attention to Likert kinds of scales but also hours of sleep or their sleep-wake
schedule, have them do graphs of it and so on and then sort of write about that. And
I'm happy to sort of talk more about that, but I wanted to you to see a sample sleep-wake
diary.
The next thing is the Epworth Sleepiness Scale. You can get this anywhere online these days,
to tell you the truth. But this is used in sleep labs. This is a standard assessment
that's used as sort of a very preliminary way of getting at whether someone may in fact
have a sleep disorder. But I think, again, it's a great way to give your students a sense
of measurement with regard to sleepiness.
Unfortunately - and, again, it could be a whole class in and of itself - there is very
poor reliability between self-report on sleepiness and if you were to do what we call an MSLT,
which is a way of estimating sleepiness in the sleep lab. If any of you have family members
who have been assessed for sleep apnea, sometimes they will stay overnight and then do this
during the day. It's where you actually ask someone to try to fall asleep to see if they
are going to fall asleep or not. If you're very sleepy, you'll fall asleep in under 5
minutes. If not, you won't fall asleep, they allow about a 20-minute window and also look
to see what sleep stage you'll go into.
And what's interesting is that with someone with a sleep disorder, like sleep apnea, you're
going to see some pretty high correlation between filling out the Epworth sleepiness
scale and what happens in the lab. But for the person who's not suffering from a sleep
disorder, there's actually very poor reliability. So in other words, an adolescent may be highly
sleep-deprived but they might fill this out, and depending on sort of the time of day and
what's going on, you might look at it or if you're doing it from a research perspective,
and that person would not look sleepy at all. So yeah, you can have some fun with it.
>>WORKSHOP PARTICIPANT: What did you take on poor reliability between self-reporting
and ...
>>WOLFSON: And any more objective measure like using polysomnography in a sleep lab.
>>WORKSHOP PARTICIPANT: Okay. Thank you.
>>WOLFSON: Yeah.
>>WORKSHOP PARTICIPANT: Two kind of related questions that I'm always mystified by: in
apnea things, a person having an apnea episode, it's completely disruptive sleep. Wherever
they are with the sleep cycle, that point is completely disrupted. They go back and
start again, or even though they don't fully wake up, what other things are there? Well,
also, when you sleep ... if you were in a sleep study and you're having your EEG and
you wake up, kind of then stumble to the bathroom and you go back to sleep again kind of half
awake. Do you start over? Do you pick up where you were? Because you said something, you
said which sleep cycle they were into when they fell asleep. So can you say a little
more about that?
>>WOLFSON: Yeah, yeah. So I actually was not going to talk about sleep stages at all today,
but I'm happy to ... I mean only because we could spend the whole morning talking about
polysomnography. But what I will say is that ... does everyone know what the question is
referring to? Okay. So in answer to your question, you don't necessarily start all over again.
Now, whether you return exactly to where you were varies from individual to individual
and how long you were awake. I mean with sleep apnea, you absolutely sort of go back into
whatever stage you were in because those are ... that which is very different than getting
up, going to the bathroom, getting back, trying to fall asleep. That's a sort of different
experience because with sleep apnea, you're having ... these are seconds that your sleep
is grossly inefficient.
And in fact, the variable of sleep efficiency is another interesting variable to have your
students calculate, which is the number or estimate, the percentage of time you're asleep
relative to the time you're in bed, which are not necessarily the same. And individuals
who have sleep disorders, it might be restless leg syndrome, periodic limb movement, and
sleep apnea have very poor sleep efficiency, or if you're just being awakened because of
a baby all night long.
But with sleep apnea, these are seconds you're waking up and then you're falling back to
sleep, and then you're waking up again. And someone with a very high severity index in
sleep apnea of course is waking up lots and lots of times, but they're minimal amounts
of time but multiple times throughout the night. And then those individuals likely,
they're sort of going back to sleep where they were. There's pretty minimal REM sleep,
though, in sleep apnea. Anyone who is sleep-deprived has less REM sleep, and what they'll experience
too is sometimes REM onset during the day if they fall asleep because we crave REM sleep
if we're deprived of REM sleep.
The next is one example. There are many of them of an owl-lark test, and this is terrific
to do with your students to give them a little bit of a flavor for self report on whether
they're more lark, or more owlish; teenagers developmentally tend to be more owl like than
they were previously. That's not to say it's relative to where they were. But the average
person, if you were to do thousands and thousands of morningness-eveningness questionnaires,
most of us fall somewhere in the middle, which is interesting. People often, you will think,
they're lark-like but then they're really far less lark-like than they thought they
were or vice versa. So these are just ... I just thought I'll give you some sense of some
of the assessment techniques.
The final handout is just something very short that I created a number of years ago to give
to middle school students shortly - or not that many years I'll say. These are pretty
recent numbers. But, Massachusetts is actually one of the few states that has started to
think about sleepy driver issues and what we should be doing from a policy perspective
to try to prevent sleepy driver motor vehicle accident. So I thought you would find this
interesting, and again, largely because you're working with teenagers. So that's what's in
the packet.
So I'm going to actually start now and I'll go through some materials to give you a sense
of what I would be. I think most of this material is accessible to most of your high school
students. You may need to tweak it somewhat, but also to educate you about what we know
about adolescent sleep today. Let's see if I got this going the right way.
Actually, oh, I have to back up. I need to have you hear this for a second if I can get
to this website. This is a great video that you can actually purchase. It's called, "Who
Needs Sleep?" I'm not going to say any ... just let you listen for two seconds.
>>[Start of video presentation]
>>FEMALE VOICE: You need to be human. There is no animal that tries to sleep-deprive itself.
>>[Music] Who needs sleep? Who needs sleep? I said I'm young, I'm strong, I can work all
night long. [Ambulance noise]
>>FEMALE VOICE: He lost his life simply for working hard.
>>MALE VOICE: One of the problems with the movie business is it does seem glamorous,
and so there are a lot of people who would say, oh, I'll do anything.
>>MALE VOICE: When they talk about capitalist with the human face, it's an oxymoron. It
can't be.
>>MALE VOICE: Nothing good happens when there's long hours.
>>FEMALE VOICE: For somebody who doesn't have regular work, they're not going to complain
about their hours because they can't afford to.
>>FEMALE VOICE: I have a five-year-old son, and I'd say that's where the conflict of this
job comes in for me personally.
>>MALE VOICE: We're the only group of industrial workers in the world fighting for a 14-hour
day.
>>[Music] Who needs sleep? Who needs sleep? Who needs sleep?
>>[End of video presentation]
>>WOLFSON: Let me see if I can get back to where I was now. Okay. You can just look that
up. It's "Who Needs Sleep?" if you go online, you can order the DVD. I use parts of it often
when I start the semester again or if I'm teaching my sleep course or for a unit on
sleep. You probably wouldn't end up using the whole documentary but it really gives
students a sense of the real life implications of understanding problems of sleep deprivation
and how that intersects with their lives and lifestyle, and it's about the movie industry
which I think works great with teaching adolescents.
There's a little bit of historical information. As I said, I'm going to go back and forth
a little bit between adolescent sleep and some broader topics. This is a really new
area, and I feel like I can still say that. I really felt I could say it when I started
teaching in the early 1990s, but it's amazing really and I think striking for your students
because unlike other dates when you talk about something, it often ... when I teach, of course
the 1960s seemed recent too, but this is particularly recent for your students. In other words,
the field was developing while their parents were starting their jobs in essence.
So sleep was certainly first characterized or described in the early 19th century, but
from 1900 to the 1960s, there was virtually no description of sleep. There is one exception,
and that's with regard to children. There's a little bit of discussion about sleep in
children around the 1920s or so, but very, very, very minimal both in the behavioral
science literature as well as the clinical and medical world.
REM sleep was first discovered in 1953, and non-REM sleep and its stages characterized
in 1957. 1961 was the founding of what's still called today the Sleep Research Society, a
great place to get resources. It's actually a very minimal membership fee. It's the organization
I belong to. A great website to check out. Also, 1971, '72 was sort of the confirmatory
discovery of the SCN, our actual biological clock. I mean that's not that long ago. It's
really, really striking in that regard.
You can really see these numbers. I won't go through all of them, but it wasn't until
1995, 1996 that the American Medical Association actually recognized sleep medicine as a sleep
specialty. Physicians and other healthcare providers can now get boarded in sleep medicine,
and, in fact, there's a new exam for behavioral scientists now. That's been developed in 2012.
Just this past June was the very first Society for Behavioral Sleep Medicine meeting. So
it's a very new field, and I think that that's sort of exciting when you're talking with
high school students and undergraduates.
These are questions I often use with my students as I'm starting a class, and I sort of tried
to fit them for you all since you teach high school students. Think back to your middle
school years. This is for you guys to think back, but convert them. When did middle school
start? What were your sleeping patterns like in middle school? Again, this is for your
students as well. What were your sleeping patterns during your first year in high school?
What about now? I think it really gets them to sort of individually get a sense of the
developmental changes that occur in sleep. Worthwhile exercise for yourselves as well.
There are really, I would argue today, three broad areas that determine human sleep. There
is some ... I think it's controversial. I'm someone who has a lot of doubts about the
genetic implications of understanding sleep or whether we really will be able to understand
genetics with regard to sleep. That will be a whole another discussion. But I do want
to point out that it is a hot area of research right now. And there's some evidence for particularly
circadian timing, genetic implications for those variables.
I'm going to talk in a couple of minutes about the bio-regulatory processes with regard to
sleep. I think it's very important to talk with your students about that, and particularly
when you're talking about adolescent sleep. And then of course, all of the behavioral,
circumstantial, that is to say clear research of socioeconomic status or environment or
living conditions have implications for one's ability to get an adequate amount of sleep
or a regular amount of sleep. Life choices, so again when you're speaking with adolescents
and talking about adolescent development, whether that's the time of day and when you
do your homework, to caffeine, to all of the technology that adolescents are using, those
are choices that they make that may have negative implications for getting an adequate amount
of sleep; and, again, as adults, occupations and again back to that documentary about the
film industry.
So what happens over our life span? I'm just going to put these three categories up and
talk about them a little bit. So some researchers use different terminology. You'll see the
terms sleep-wake homeostatic process or you'll also see the term Process S from Borbély's
work. But this is referring to, basically we have ... there's a ratio going on throughout
the day. Basically, the longer we go from when we last sleep, our biological drive to
sleep, for sleep gets greater, and that's what's really the sleep-wake homeostatic process.
So literary, we become more sleepy relative to when we last slept or the amount of sleep
we've been getting. At that point, I'm just talking about processes. I'm not talking about
time of day at all.
And the best example - I didn't bring this picture, but after the Oklahoma City bombings,
a number of - just like after any awful disaster - there were some Red Cross emergency care
workers who were photographed, and this photo ended up all over many, many papers throughout
the United States and elsewhere. And it was three workers I believe who have fallen asleep;
they were up against some mesh fencing that had been put up around the area they were
trying to sort of clean up after the awful, awful disaster. And these three individuals
were asleep, and there was a terrible cartoon note after that, something sarcastic that
some journalist wrote, something like asleep on the job. Well, you know, guess what? It
turns out they've been awake for more than 36 hours, and it doesn't matter how motivated
you are, although motivation is something that can override sleep temporarily - I'm
certainly good at that myself - but eventually there is a biological drive to sleep. So that's
Process S.
Process C relates to circadian rhythms. And just a brief, little bit, again I'm not going
to spend ... again, we could do a whole class just on circadian rhythms. You could do a
whole course or a whole semester on circadian rhythms. But again, as I said earlier, that
relates to our biological clock. And there are times throughout the day or throughout
a 24-hour period, the human clock is about 24.3 but there are individual differences.
Chuck Czeisler who's at Harvard really demonstrated now, oh goodness, 15 years ago or so; there
was a belief that the biological clock, the SCN, the suprachiasmatic nucleus might vary
from 24 to 28 hours. That is not true. It's pretty clear that it hovers around 24.3 or
so. There is terrific and exciting research being done on adolescents by my colleague,
Mary Carskadon, to try to get a sense developmentally of whether that clock changes prior to puberty,
throughout puberty, and then post-adolescence, but that's sort of the number we still talk
about, 24.3 or so.
But what's more important is to understand that depending on where core body temperature
is, internal body temperature is, or where melatonin is, which is a hormone secreted
by the pineal gland, as well as other external, what we calls zeitgebers, other factors out
in the environment where your clock is. And you're going to be, as I said earlier when
we were talking about motor vehicle accidents, you're also going to be more sleepy or more
alert throughout the day, not just based on when you last slept, so not just based on
Process S, but also based on where your clock is. And so there are particular times during
24 hours where we're more alert or we're more awake.
For example, whatever our individual time is that we're most likely to fall asleep in
the evening as humans, we are diurnal - so for me, that's going to be around 10:00, 10:30
- about an hour to an hour-and-a-half before that, my melatonin level is peaking. It's
going to be at its highest level, troughing closer to the ideal time for me when I'm going
to wake up in the morning. But then throughout the 24 hours, melatonin and core body temperature
peak and trough as well. So you have the sleep load that I've talked about, the sleep-wake
homeostatic process, Process S. You have our circadian drive for wakefulness as what it's
referred to, again, so this is pointing out different times throughout the 24-hour period
where we're more likely to be asleep or awake. And again, this is the evening hour as human
beings.
And then we have wake propensity, which is referring to all the other factors that are
going to influence our ability to maintain wakefulness throughout the day, which refers
to lighting, which refers to other individual factors. It might refer to be included, as
I said, substances that are in your body, types of food we're eating, our moods and
so on.
This graph works really well. I do think that high school students can understand it. It's
easy to get. I have the reference here.
But I think the key question when you're talking to your own high school students and talking
to adolescents or my talking to you about them today is why do adolescents struggle
against going to sleep in the evening and struggling to wake up in the morning? And
we're basically going to talk about that for a couple of minutes.
A couple cartoons of - these are great. I don't know those of you, since you teach high
school students, if you're familiar with Zits. I think anyone who works with adolescents
needs to read the Zits cartoon on a regular basis. A funny story: my colleague who was
really one of the preeminent and founders of understanding adolescents and sleep, Mary
Carskadon, who was at Brown. I was at a holiday party. This is now back I want to say five
years ago. And she had little grab bag gifts that you could pick up, and she did these
desk calendars for everybody. And this happened to be the ... I mean, other people picked
up all kinds of desktop calendars. I happen to pick up the Zits calendar. And, literally,
this is January 31st of the next year, for days in a row, the cartoons were about sleep.
I mean it was hysterical about adolescent sleep.
So, a couple just great ones that are so poignant in terms of the questions that we're talking
about today: well, whoa, look at the snow, whoa, tobogganing, build a snowman, cross-country
skiing, make caramel corn. What should we do first? Well, by first, I assume you mean
after going back to bed for five hours or so ... talking with his mother. And then I
love this pose. It's this generational or developmental. Your generation totally messed
up the planet through its greed, incompetence, and apathy. You're probably the most arrogant
group of people in history. Well, I'm sure your generation will do a better job should
any of you ever manage to get out of bed before noon. And why do you always have to be so
critical? I'll let you answer that question.
And then I have these reversed. I apologize, but if you sort of look at these from January
9th and January 10th again, it's just absolutely hysterical. It's just one after the next.
So he's yawning. He's in the kitchen. Poor baby, you were up late doing homework and
you fell asleep on your desk again. Yeah. How do you know? You can spot the really dedicated
students by the spiral notebook marks on their cheeks or those who are getting insufficient
amounts of sleep.
And then here we go: so what goes on as we move on to college? It seems wrong for you
to have six hours of homework every night, Jeremy. It's not just me, mom. Everybody has
it. That's just the way it is. And the AP classes only make it worse - not AP psych.
Then it's going to be like this all through high school. Yeah, most of us are looking
forward to starting college so we can get some rest. [Laughter]
I know [laughs]. So what happens?
So adolescents ... and I don't know what definition you use, Nancy. I think, I mean I talk about
sort of straight through the college years as your colleague talks about whether ... at
what point are the college years emerging, adulthood, or are they still adolescents,
is I think a question. I think you've thought about this before, and it's probably worthwhile
to remind your students of this when you're talking. I mean such a vast amount of psychology
research as well as health science research has been done on college age students in the
United States and elsewhere, and still to this day, in a totally age developmental perspective.
In other words ... and sleep included, we know far more today about adolescent sleep
than we do about sleep in the college years. And a lot of studies are done on sort of learning
and sleep and memory and sleep and so on using college students as research subjects, without
thinking about that from a developmental perspective. It is starting to change, but it remains a
serious concern in my opinion.
So one example of that, before I go through this but while I'm thinking about it, is I'm
going to talk about developmental changes that occur over this period of time with regard
to sleep and circadian timing, and yet we know very little about what happens from age
about 18 to 22. There's a little bit of research, and I'll
comment on it in a minute, but in other words when does sleep look more adult-like remains
a question. When does that occur? And what are the factors that influence that? In other
words, is that environmental? Is that something going on that's physiological or biological?
Is that, have to do with the type of lifestyle you lead over those years and so on?
But what we do know is that adolescents report, self-report as well as using other measurement
techniques, less sleep than younger children. They start to show irregular sleep-wake schedules
sometime towards the late elementary school age years and middle school years. In other
words, their sleep schedule looking different during the week from weekends. That bed and
rise times become increasingly more delayed; that is to say going to bed later and actually
waking up later over the same period of time. That school wake or rise times are constrained,
are very much related to the timing of whatever your school district sets that schedule for;
that the amount of sleep or the sleep length over the adolescent years declines. And I'll
show you some graphs that demonstrate that. And that the size of the school night to weekend
discrepancy, both timing and amount, is tied to, as I already said, very negative outcomes.
The more erratic your sleep-wake schedule is, has negative implications for cognitive
functioning, for emotional well-being, for risk for substance abuse and so on.
These are old graphs but I just keep them in my battery of numbers of slides because
study after study has demonstrated this. This is data from 3,000 high school students from
Rhode Island from back in the late 1990s, back in the day. And you can see bedtime is
getting later over the high school years. This is self-report data, but actigraphy data,
which I'll comment on in a minute, replicates these findings.
This is data from a study that was published just about a year-and-a-half ago where they
gathered together a number of studies that have looked at adolescent sleep actually from
their early adolescent years through age 18. And what you can see, although the studies
vary in terms of where the populations were studied across the world - this is worldwide
data; the researcher here is actually from Australia - but you can see the same pattern.
Their bedtimes, if you look at the graph in the broadest perspective, bedtime is getting
later. The same with the total amount of sleep, again, you can see sleep gets ... and there's
about a 40-minute difference. This was statistically significant. Again, this is reported now in
study after study. And again, similarly, slightly less extreme when you pull a number of studies
together, but you can see that if you look a lot of datasets, you see the same findings.
There's some variability country to country, but the overall pattern is the same.
This is actigraphy. Let me see. Are you familiar with what actigraphy is? Is that something?
So let me say a little bit about it. It's not something that you would easily be able
to do with your ... well, I shouldn't say that. These days with what's happening with
cell phones and whatnot, you might be able to. So actigraphy is the way that we estimate
sleep in the field. In other words, you can't study 200 middle school students and bring
them in to a sleep lab to understand their sleep. So we estimate sleep in a more objective
way in adolescents - this is what my lab does - by using actigraphy, which is based on accelerometer
technology. It looks like a watch. Sleep researchers and other behavioral scientists learned many,
many years ago that we can use movement to estimate sleep. That is to say, we are on
average far more active even when you're sitting here listening to me when we're awake than
when we're asleep. So corroborated with sleep-wake diaries, we use actigraphy to estimate. It's
not measuring sleep. And I always remind my students, this is not measuring sleep. It
is estimating sleep, the same way self-report is estimating whatever it is that we're trying
to get at. So this looks like a watch band. These new actigraphs that I'm using in my
lab also measure light. So I'm very interested in the impact of light on adolescent sleep.
But this is what it looks like. And now, what?
>>WORKSHOP PARTICIPANT: It measures movement or light?
>>WOLFSON: It measures movement. Well, this one measures movement and light.
Accelerometer technology is, for those of you who are techy folks, is what's in iPads
and cell phones and so on. In fact, there is an accelerometer in most iPads and smart
phones. And in fact, you can get simple and I would just say experiment yourselves with
your students, you can now get apps on their cell phones and on iPads that would allow
you to just do a simple experiment. They could actually do fill out a sleep-wake diary and
use one of the apps if they have a smart phone or if you have a few that they can share and
could actually do a simple experiment comparing what their self-report of sleep-wake information
is by using the accelerometer technology on an iPad or an iPhone.
LARK is the company to look up. If you look that company up, it's possible even ... they're
very inexpensive. So in addition to your being able to just play with an app, you could now
get some very inexpensive actigraphs. Perhaps if you have, I don't know, budget sizes and
some of you may be in school districts, so this would be absolutely impossible, but those
of you who are in a school district where you could pretty minimally. This company called
LARK ...
>>WORKSHOP PARTICIPANT: Can you spell it?
>>WOLFSON: L-A-R-K, now makes a device for the general public that is similar to these
thousand-dollar actigraphs that we use in my lab for just a couple of hundred dollars.
So you might be able to even purchase a couple or over a couple of years slowly purchase
them and use them to do some very interesting projects with your students where they could
compare their data from accelerometer technology to self-report. Neat stuff.
And I use this as a segue to talk about ... this is just real data from my lab where we were
looking at middle school students. Two different samples - this is sixth, seventh, and eighth
grade from one district and then some seventh grade data here from Worcester. And again,
this is just giving you a sense that it's less so in the early middle school years,
but what you're basically seeing is the amount of sleep that kids are getting over this middle
school period of time, and what you're seeing is although it looks like these Worcester
kids were getting more sleep, the main thing I want you to look at is how much less sleep
eighth graders were getting from sixth and seventh graders. So, corroborating with self-report.
And, same with sleep onset time. We actually use the term onset when we're using actigraphy
to differentiate that between that's really the estimated time someone falls asleep as
opposed to bedtime being the time you might get into bed. So that's just a slightly different
terminology. Again, getting later from sixth grade versus eighth grade.
This is what an actogram looks like. So when you get data from actigraphy, this is what
it looks like. And basically, you're looking at a week's worth of time here on the Y-axis.
On the X-axis is time. This is 9:00 in the morning to ... excuse me, yeah, 9:00 in the
morning is over here. But basically, what you're looking at is the dark area is showing
when the person is awake, that's movement. And this red area is when sleep is being scored
by the program that we use in my lab, but that's corroborated. We score that also relative
to diary times, and I won't go into detail about that. But what I want you to look at
here which is, again, something you could do with your students, and I'll send you to
a website. If you don't even have actigraphy and you just want to get samples of this,
if you go to either the Ambulatory Monitoring website, AMI, they're one of the companies
that makes the type of actigraph I'm passing out. You could also go to the Respironics
website, and they have all their product information but with the product information, they have
sample actograms if you just want to show your students.
But what's most striking about the difference between these two actograms without even knowing
numbers or anything?
>>WORKSHOP PARTICIPANT: Regular and irregular sleep.
>>WOLFSON: So, first of all, right, the seventh grade male has a much more regular sleep-wake
pattern. I mean it's clean as a valve. He's falling asleep about the same time and waking
up about the same time every single day across that week. And this female ... and I'm not
trying to suggest gender differences. I mean there is research suggesting there may be,
but I'm not suggesting that by these two examples. And then the seventh grade female you can
see is getting significantly less sleep, just eyeballing it, and has a much more erratic
sleep-wake schedule. It's pretty profound. I'm going to just move on here.
Okay. So now, what I've mentioned so far has to do with self-report and actigraphically
estimated sleep-wake patterns over this adolescent period. And as we've said, they're getting
less sleep and they're going to bed later. Pretty much, if you look at datasets from
age 11 or sixth grade through the end of the high school years, you see this distinct pattern.
But what else is going on? There are also some very striking and remarkable changes
that are also occurring. First of all, we have very clear research that was done all
the way back in the 1980s by Mary Carskadon and colleagues that demonstrate that sleep
need does not change over the adolescent years, or from elementary school through adolescence.
That is to say prior to the early 1980s -that's not what's exactly on this graph here - prior
to the 1980s, there was a belief that we need less and less sleep as we get older. People
used to imagine literally you would sort of get to be 75 and you could get by on no sleep.
There were these assumptions about a linear story. That's just not true at all.
A beautiful study done in the early 1980s by my colleague, Mary Carskadon and Bill Dement,
William Dement, who was one of the sort of grandfathers of modern sleep science in the
lab when REM sleep was developed. She was his graduate student. They did a study where
they brought over consecutive years ... they followed the same kids who were Tanner stage
zero or one, so prepubescent, through Tanner stage five, fully developed. They followed
these kids both individually and looking at them as a group over several years. And in
this study, they would bring them into a sleep lab for a week. They were allowed to sleep
as long as they could every night, although they were awakened after about 10 hours every
single morning.
And what they discovered is regardless of Tanner stage and regardless of chronological
age that the mean amount of sleep over that period, both following these kids longitudinally
as well as individually, was 9.2 hours. And almost, in fact, they really talk about the
standard deviations from that study because they were virtually nonexistent. There were
very little individual differences, both within individual and over time. And if anything,
it was the Tanner stage four and five kids and the older adolescents around age 15 who
actually had to be awakened at the 10-hour point and not the younger adolescents.
It's a beautiful study. It's never been entirely replicated, but it is used to demonstrate
sleep need, and most people accept it as, really, at least understanding the fact that
regardless of the exact amount that sleep need does not change over that period of time.
So if you think back to those self-report graphs I showed you, that means that the younger
adolescents, the sixth graders, are probably getting an adequate amount of sleep or a sufficient
amount of sleep, and as kids get older, they are increasingly more sleep-deprived. They
get further from that 9.2-hour mark. Very, very important study that is still talked
about these many years later.
What I also want to talk about is some data from a study that I was a coauthor on, and
that was a study that was done ... we called it the sleep start time study. And it was
really one of the first studies in a laboratory setting to demonstrate the problem with early
school start times relative to adolescent sleep need and timing of sleep. And so I'll
say a little bit about this study because it really gives you a sense of how difficult
it is for your students and your high schools and then the students you're teaching when
you talk about this topic to function with an early school start time.
So in this study, we studied adolescents. These were ninth graders transitioning to
tenth grade in some Rhode Island schools. And we studied them in the spring of ninth
grade, the summer before tenth grade, and the fall of tenth grade. This was an old-fashioned
school district. There aren't too many like this anymore where they still called it junior
high and the kids were transitioning from ninth to tenth grade - high school started
in tenth grade. But what was key and why we chose this school district is there was an
over-hour difference between the time they started ninth grade in junior high or middle
school and what time they were going to have to start tenth grade in the fall of tenth
grade. And we were interested in seeing what was going to happen over that period of time
both in terms of their real life, so they were actigraphed for a week. We got a sense
based on the actigraphs of what their school week sleep-wake schedule was, then we brought
them into the sleep lab either on a Friday or a Saturday night, but we kept them on their
school night sleep-wake schedule. So if they went to bed at 11:00 that's the time they
were allowed to go to sleep. And if they had to be, they were waking up to go to school
at 6:00 that's the time they were awakened on either Saturday or Sunday morning in the
sleep lab.
But what we also studied is prior to the time they were going to sleep, we collected salivary
melatonin, which is what's used to estimate where their circadian clock is, the timing
of their own clock. And I won't go into all the details of that, but we did that. So they
were spitting to collect saliva before their estimated sleep onset time and then the following
morning again, after they're awakened, after they've been on their school schedule all
week going to school and came into the sleep lab. We kept them that night. We didn't let
them binge sleep, so they got that, whatever their number of hours. If they were getting
seven hours of sleep, they got seven hours of sleep that night.
And then we did the MSLT - this is what we called laboratory nap test - during the day
at 8:30 AM, 10:30 AM, 12:30, and 2:30 to see how long it took them to fall asleep. We wanted
to get an objective estimate of how sleepy they were on this short sleep-wake schedule
they were on with their various school start times.
And so what we found is that when we compared - I won't talk about the summer -- but when
we compared spring of ninth grade, say March-April - we always make sure we collect data; we
pay attention to when the clocks are being changed - and then the same thing in the fall
after they've been in the new high school schedule for about a month. What you're seeing
here is tenth grade data. So what you're seeing is the mean number of minutes that it took
them to fall asleep on the 8:30 nap test - that's sort of our colloquial name for that - was
about five minutes. That is pathological. And these kids were screened for both their
own history of narcolepsy and a family history of narcolepsy and other sleep disorders. These
are kids who are normal, no sleep disorders. These kids looked like they had narcolepsy.
And in fact, 50 percent of these kids on the 8:30 nap test went into REM sleep.
This study was published in 1998. I'm not saying this because of my involvement in it.
It has not been replicated, but it is the study that you really have to come back to
when you're trying to talk to people about why it is that starting school at 7:00 or
7:30 or even 8:00 in the morning for middle school and high school students is highly
problematic. You're basically asking kids to come study calculus or pre-calculus or
AP psychology or tenth grade English and read Shakespeare or whatever you're doing in your
courses, when their drive to sleep, because they're so sleep deprived and because there's
a circadian phase delay, which we haven't gotten to yet, is problematic.
The other thing that's going on is it isn't just that these kids are sleep deprived. It's
also that we know ... and I'm not going to go into all the details of the study, that
study I should say that I just talked about. It also suggested the circadian sleep delay.
But what we know is that also over those years, there's a delay in the timing of sleep that
isn't just, oh, there's lots going on; I want to stay awake to socialize. That's part of
it. That's absolutely part of it as the slide suggests, but what we also know is that when
you remove the environmental constraints, there's a delay in the timing of sleep as
well. So what does that mean?
On that same study that I mentioned, we found that the kids that their melatonin over this
developmental period of time, that the time that melatonin was peaking was getting later
in the evening regardless of other factors. And you're controlling other factors. So that
means that the clock is basically shifting, and the time that you're going to naturally
fall asleep, regardless of all the external factors, is later in the day. So there are
two sort of major variables that are coming together over this adolescent period to sort
of create the perfect storm for why adolescents are so sleep-deprived and why of course many
of us sort of argue that early high school start times are creating a perfect storm,
so to speak, or adding to the perfect storm.
Just one second. Can I have just one second?
So, between the -- if you do the math and you say, okay, we know from research done
all the way back in the 1980s that sleep need is about nine hours. We all often say 8.5
to 9.5 hours. And you don't have to be a mathematician to then look at the time that the average
adolescent is likely to be biologically able to fall asleep, say, is 11:00, 11:30 and then
you draw out those nine hours, any of your school districts that are starting before
about 8:30 in the morning are creating or adding to the perfect storm. Your question?
Sorry.
>>WORKSHOP PARTICIPANT: You said five minutes was pathological.
>>WOLFSON: Yes, falling asleep in under five minutes. Okay. If you should've gotten an
adequate amount of sleep during the night, suggests sleep deprivation.
>>WORKSHOP PARTICIPANT: So, like for kids. What about for adults, this works as well?
>>WOLFSON: Absolutely. The amount of sleep is different. The sleep need for adults is
more, about eight hours, and there have been similar research to demonstrate that.
>>WORKSHOP PARTICIPANT: [unclear]
>>WOLFSON: Absolutely, yeah. And so this is just showing you the sleep-wake schedule of
an adult versus a teenager, and the red line showing you the delayed timing of the clock.
So just one more study I want to mention that's really interesting. A lot of people ask, and
your high school students might ask you this, all these changes are going on if you're talking
about adolescent development. Well, what comes first? Because a lot of kids will say, "Well,
I remember feeling like I could stay up later and I was only in sixth grade, and I don't
think I was very developed, Professor Wolfson. I think I still looked like," I don't think
any boys will say this, "but I still looked like I was 10 even though I was 14, but I
think I was staying up later."
So what's the order of this? And we don't really know this. It's possible from a study
done by some colleagues of mine, Avi Sadeh who's at the University of Tel Aviv and Ron
Dahl and some others, studied youngsters, 9- to 11-year-olds, boys and girls. And what
they were able to demonstrate in this study, but it has not been replicated, is it looked
like pubertal changes in sleep, as they called them, that is to say more disruptive sleep,
more erratic sleep, more delayed sleep, less sleep, these variables that I'm talking about,
using actigraphy seemed to actually precede bodily changes, so Tanner staging. And so
it's possible that some of the sleep changes may almost be precursors to the onset or adolescent
development. It is not been replicated, and there's a number of holes that can be punched
in the study, although it's an elegant study, but I think it's important to keep in mind.
The other, and this field, there's a new study published constantly now in the field, but
another really interesting 2005 study by Oskar Jenni and actually Mary Carskadon was involved
in this study and others also suggest - remember back to Process S -- also suggest that there
might be a slower accumulation of the sleep-wake homeostatic pressure, this drive to sleep,
this biological drive to sleep over the adolescent period of time, which may almost create a
myth for adolescents because they think they can stay up later because they're able to
kind of push against that biological drive to sleep more than they could when they were
younger. That's not to say they don't still need that sleep, but we, as adults, get basically
better and better at holding off that biological drive to sleep even though we need to sleep.
And I call this the sleepover problem - my own name. And many of you may be parents or
currently have kids in your home. It's the famous case of when you have a 10-year-old
or let's just say a 7-year-old. And I don't know, sleepovers just got so popular. I remember
being shocked that my 6-year-old was invited to sleepover at someone's house. Okay. And
if you let them, let's go with the 9-year-old and the 10-year old, they sleep over their
best friend's house, and it's hell to pay - excuse my language - on Sunday if you're
the parent. Now they're home with you, and trying to get that child to do homework or
be cooperative, I don't care, even the best well-behaved kid is awful on that Sunday,
right? I remember thinking, please, no sleepovers. Whereas, if you think about it, your eleventh
grader might have hang out with friends and been up quite late and they act sort of okay
on Sunday. It's not so bad. They seemed to ... at least those that function relatively
well "managed to get by," in quotes. That's the behavioral story that's tied to that research
study.
Okay, I talked about this study already, so I'm going to pass through this and get to
here.
So this is not my diagram. I actually found this quite a number of years ago online at
this website, scienceblogs.com, in 2006, and I jazzed it up a little bit. But I think this
basically summarizes everything we've talked about already. I think it's a nice graph to
think about what's going on for the adolescent, the vicious cycle of the teenager's sleep.
So let's start at the top. Does this thing have a pointer? Yeah. If we start at the top
... so as we've already said, due to both the circadian clock delays, delay in the circadian
timing of sleep as well as all the activities that adolescents are involved in, they stay
up later and later over the adolescent years. The latest top one, and I'll show you a little
bit of data on that, is text messaging, et cetera. It's awful, by the way. We're just
in an awful stage. The cell phone left on all night long and adolescents answer and
text message all night long.
>>WORKSHOP PARTICIPANT: I'm living this right now.
>>WOLFSON: Yeah. I mean, basically, really, we should be removing cell phones from the
bedroom. Okay. So it gets later and later. They need the sleep requirement but their
accumulated sleep data over the week. Also, what's going on is they're getting inadequate
amount of sleep because they have to get up so early in the morning because of early school
start times. So then, what happens on the weekends? They sleep in. They go back on their
natural schedule and they also are binge sleeping. So in other words, on the weekend, you're
staying up later, going to bed late Friday night, later Saturday night, sleeping in Sunday
morning. What happens on Sunday night?
>>WORKSHOP PARTICIPANT: You can't go to sleep.
>>WOLFSON: You can't fall asleep, right? It's even later than before, and so the cycle starts
all over again. Particularly problematic in school districts where kids have to be in
school before I would say 8:30, 8:45 in the morning. Again, do the math. Okay?
And some of you are probably living or experiencing or working with adolescents where your students
are coming to school and they're starting school at a time that might be up to two,
two-and-a-half hours earlier than what fits their schedule. Okay.
So you reinforce -- this gets reinforced. They're up even later Sunday night. Some kids
may already be using alcohol to fall asleep or doing something or borrowing or looking
for sedatives. Kids who are at risk for substance abuse, I think that is going on. So they can't
fall asleep Sunday night. Sleep gets restricted. You start to see all the consequences of this
during the week for some kids; academic difficulties, emotional liability, even risk for depression.
And again, I've mentioned drowsy driving.
And then I think kids are using their own countermeasure. I don't think we have enough
research to prove that yet, but I think we have a percentage of adolescents who are using
their own countermeasure. In other words, they are intervening. You're teaching psych.
They're not doing the best intervention. They are using their own intervention okay -- Dunkin
Donuts, et cetera. We'll talk a little bit about some of this and then we're going to
have some fun momentarily.
I literally, on each of these topics, could do a lecture and talk to you. And you'll have
to choose where you want to go with this with your students if you develop a unit on sleep
and adolescent sleep in your psych classes or in other courses that you teach. I mean,
there's a growing, fascinating research on social class and culture I've become very
interested in. How many of you teach inner city or urban districts? So I think you have
a whole added issue for kids in those areas, and a very understudied area. I think I may
have given you the study to read.
We have data now from Worcester public schools where we have a very high percentage of children
living in the school district out or below the poverty line. You can see one of the neighborhoods
here, Clark University. And these children are living in environments where they're sharing
bedrooms; possibly there's an infant in the same room that a ninth grader is sleeping;
where there are greater noise levels, more televisions; and even in upper middle class
families, possibly noisy neighborhoods, so in addition, possibly families working shift
schedules or people coming in and out of the homes. In published data now, and my study
is one among a number, suggesting that these kids are getting less sleep and have more
erratic sleep-wake schedules - not surprising. I don't mean to sound naïve about this but
finally some data - than kids who are in middle class and upper middle class families. You
put those students in school districts that start early in the morning and you further,
you put them at greater risk. You don't have to, again, sort of do the research, even though
I'm all about research to make those, draw those conclusions. Whole area - screens and
media growing. I mean, your students will love ... and again, if you email me, there
are some fun studies now coming out that you can talk with your students about.
The National Sleep Foundation did a survey where they over-surveyed high school students
and college age or emerging adults to get a sense of the impact of technology on sleep
and what are the most cogent and striking findings. And if you go to the National Sleep
Foundation website, you can get this data. I'll be happy to help you find it. But just
one stat alone is just so compelling and it just follows. I think about 19 percent of
the 13- to 18-year-olds and the 19- to I think it was 22-year-olds or some such cutoff, so
again high school and college age, self-reported that at least a couple times a week they were
waking up to respond to or send a text message - 19 percent - and these were thousands of
telephone-surveyed individuals. Okay. That is basically like creating sleep apnea with
text messaging - back to your question.
Employment, there is some compelling work that I did quite a number of years ago, and
I think there needs to be more work done in this area. But high school students, there
was work done by Laurence Steinberg who's a developmental psychologist many years ago.
He's probably cited in some of your textbooks that you use where we he looked at employment
in adolescence. It's, first of all, far more likely that upper middle class kids in this
... I mean, again, things have changed with the economy. But for quite a long time, middle
and upper middle class high school students were working who didn't necessarily have to
work for financial reasons, and those working 20 hours a week or more in addition to going
to high school were actually at greater risk for academic difficulties than those not working.
People tend to think the opposite. Sometimes parents think the opposite, oh, it creates
great confidence, et cetera.
Well, unfortunately, also was sleep. Adolescents who worked 20 hours or more a week actually
have grossly more inadequate and more irregular sleep-wake schedules than adolescents who
don't work at all or who work under 20 hours. So the risk factor seems to be the 20 hours
or more. So again, some interesting work.
And then caffeine, I'll talk a little bit about that, and of course high school start
times. I love some of the things, some of the kinds of sort of media things that you
can show your students that are so disturbing, or in this case maybe not disturbing but a
suggestion of how concerned people are getting about these issues.
This was from I was on a trip, American Airlines, their magazine, American Airlines Magazine.
And one of the main articles in this issue of March 2010 was about families who were
sending their kids to camps that were going unplugged; back to the old days, real letter
writing, no emails, no websites where you can see your kids online and so on. So I'll
get this back up -- I didn't end up including the studies on this topic, but I'm happy to
make suggestions. There's a growing literature clearly demonstrating, as I said, about the
impact of technology.
Caffeine, I did want to just say a little bit about this study that I was involved in
just to get you thinking about this as a whole area to pay attention to. First of all, prevalence:
if you compare alcohol and marijuana and tobacco, those are the sort of latest prevalence data.
And yet, if you look at caffeine, adolescents increased 70 percent in the past 30 years
in terms of caffeine use. So when people say, "Oh, my parents let me have coffee, like I
think back, my parents, you know, Sunday mornings I got to have my cafe au lait with breakfast
or whatever." We're living in a whole another world now in terms of caffeine. Yeah?
>>WORKSHOP PARTICIPANT: Now that there's research to back this up, should there be either nationwide
or school-wide or state-wide policy?
>>WOLFSON: That's a great question.
>>WORKSHOP PARTICIPANT: As teachers, I know we see more Red Bull and Starbucks than I
have in the last two years - Monster - than I've ever seen . Do the schools need to step
it up? Colleges and high schools both can say we're going to ban this?
>>WOLFSON: You guys should start talking about it, absolutely. I'm part of a group. We have
a policy statement that will be coming out soon on school start times that will be published
in the American Academy of Pediatrics. And with that, we have an updated adolescent sleep
report that's going to be also published where we've written a caffeine section. We weren't
ready to actually make policy statements yet, but I think that that's where we're heading.
As you know, Bill Clinton was very involved in this pushing the American Beverage Association
a couple of years ago. He got involved. And it was all around obesity, and so there's
now a ban I think, or I don't know how enforced it is, but most, I think, schools and other
public settings, middle school ... right, middle school, you can't have sodas or certain
types of beverages in your vending machines. But high schools, because the focus there
was on sugar and not caffeine, can have diet coke in vending machines because they didn't
pay attention to caffeine. Caffeine was not the issue.
But yes, I mean, I think it's very, very disturbing. And, I mean, I would encourage those of you
who are in the secondary school world to start talking about it. I mean, Red Bull in particular,
I'm going to show you a slide. Red Bull in particular is a very scary company, in my
opinion, in terms of its marketing athletes basically. And now ... it used to be high-risk
sports where they would be showing up and advertising, promoting their products, but
now I understand if your students are on the tennis team, the golf team, it doesn't matter
the type of sport, the Red Bull machines are showing up in golf settings and tennis and
so on. But I can tell you a little bit about the data too. But yeah?
>>WORKSHOP PARTICIPANT: I just think this is a good opportunity for us as teachers.
>>WOLFSON: Absolutely.
>>WORKSHOP PARTICIPANT: This would be a great debate topic. Give them an opportunity to
look at some of the numbers in your studies and take into consideration their own wants
and needs. And what keeps coming to mind is you snooze, you lose, and then taking ... that's
the pressure that many of them are living with. So maybe on one side of it, like, well,
yeah, I'm not losing ...
>>WOLFSON: And from a research perspective, so the sleep world for so long with adults
talked about caffeine as a countermeasure, believe it or not. Okay. So if you're talking
about pilots, we would say, well, a little caffeine, if you can't get on the right schedule,
might help, if you can't get that 30-minute nap. And there's been research demonstrating
it has the same kind of positive implications. So for those of us who'd get on an airplane,
we'd like to have that pilot. If the pilot is not on a great schedule to have their Red
Bull or to be put on a prescription for modafinil, which is a stimulant used to treat narcolepsy
but off-label use to treat other forms of sleepiness and fatigue. But we're talking
about a really different scene when we're talking about adolescents. So, absolutely.
And I'm going to do a different exercise, but yes, you could do an exercise.
>>WORKSHOP PARTICIPANT: I haven't seen the 5-hour ENERGY in my high school.
>>WOLFSON: You haven't seen what?
>>WORKSHOP PARTICIPANT: 5-hour ENERGY. I don't know why kids aren't really hanging on that
one because I mean ... I don't know about anybody else, the other schools, but I just
don't see it as much. They advertise as much on TV, but I don't see kids walking around
with it.
>>WORKSHOP PARTICIPANT: They probably drink it up in their lockers.
>>WOLFSON: I don't know. Again, I didn't bring it. If you Google the history on ...
>>WORKSHOP PARTICIPANTS: [cross talking]
>>WOLFSON: This is a hot topic. All right, let me take two more questions and then I'd
like to move on. Yeah?
>>WORKSHOP PARTICIPANT: Are there any studies of, correlating early school start times with
lower academic performance in those first or second period classes? In other words,
those ...
>>WOLFSON: I'm going to show you some of that data in just a minute, but not specifically
on those; lower academic performance but not necessarily tied to specific class periods.
>>WORKSHOP PARTICIPANT: I'd like to my school to kind of push this issue. We start at 7:40.
Anecdotally, for me, it's a disaster.
>>WOLFSON: Hold off. We're going to do an exercise in just a second, okay? I'm going
to ask to just hold off questions for just one more minute. What I just want to show
you here just so you know. These are the implications of caffeine in sleep: reduces slow-wave sleep,
increases sleep onset latency and night wakening - it's not surprising - decreases sleep proficiency
- not surprising - decreases the amount of sleep, increases morning sleepiness, and obviously
a negative impact on sleep quality. And this has been found in adolescents as well.
I'm just going to move on. I'm actually, what I do want to point out, this is a dataset
we have. I just want to show you one finding of close to 200 high school students. It's
a convenient sample; school district, kind of working class school district in Central
Massachusetts.
But what I do want to show you is this. We broke this sample into three groupings. We
broke them down into ... again, virtually all the kids, 96 percent were using some amount
of caffeine. But we were able to categorize the kids as ninth through twelfth grade - and
there were no age differences in this study, no class -- no year in school differences
- to a mixed use group. So these are kids who are using caffeine of all different types
to what we call a high soda use, so pretty much their use was in soda and not in other
types of beverages. This study by the way was done prior to the Red Bull craze, just
prior, so energy drinks were not the big item. And a low caffeine user, not a non-user, a
low user.
And we found really strikingly different behavioral patterns between these three groups.
We found that those who were the mixed use group tended to use caffeine earlier in the
day. They were consuming more caffeine pills. Again, they were a mixed use group. And they
woke up earlier on school days, and they reported more daytime sleepiness. But it's the next
bullet that's the most interesting. When you compared the two high users, mixed use versus
soda, really different what we called reasons for use and expectancies for use, which is
how ... these are terms that the substance abuse literature uses. The mixed use kids,
males and females, were more likely to use caffeine, to acknowledge that they were using
caffeine, to get through the day, to have fun and experiment, and, in the red, expected
more dependence symptoms and energy enhancement.
My colleague who's a substance use researcher in adolescents is really struck by these findings,
Alison Ludden, in the sense that she is starting to, as I said earlier this morning, to think
that possibly the caffeine in a particular group of kids, possibly those who are most
affected by sleep deprivation as well, as a high-risk group. It isn't just that they're
having the Red Bull and when high school is over that they're done with it. And there's
now more and more research about this that there's high correlation between Red Bull
and marijuana use and so on. But that's not what we're ...
And, I just love this. I was skiing with my husband, and this was in Canada, and this
is not part of a ski lodge. Red Bull has now positioned itself - I guess they have permission
- to stick Red Bull vending ... not machines. In this case, cute little ski hut, right?
That's just a freestanding hut, and there's no person there. There are just machines you
can go to, to put your coins in right at the bottom by the chairlift to get your Red Bull.
It's amazing.
But this has been around forever. My son goes to school in Schenectady, New York where Union
is, and this was on the board. This is near the GE plant in Schenectady: "Drink Coca-Cola.
It relieves fatigue. Sold for five cents." So it's not as if we haven't attempted these
... marketers haven't tried this before.
So I'm going to actually move on. I'm not going to go through these slides and get to
school start times.
So what do we do? What kinds of preventive interventions can we develop - you're talking
to kids, students at a psychology class - to make sure, because we know that insufficient
sleep and erratic sleep has negative consequences for mood, possibly for risk for substance
abuse, for academic performance issues? I could have done a whole class also on the
latest research on memory, on cognition, and all the variables that relate to academic
performance more than experimental level. What are we going to do about it? And so you've
been making comments all morning long about the question of school start times. I want
to say a little bit about that and then we're going to have some fun with this, and, again,
an exercise that you can replicate with your students.
So I tend to -- this is actually not just psychology terminology but sort of those who
were in the transportation industry use the terminology countermeasures, so not just therapeutic
interventions but countermeasures. Or public health individuals use this term. So we have
systematic countermeasures that we need to be thinking about to increase sleep or get
adolescents to have more regular sleep-wake schedules. The one that's talked about the
most these days, in my opinion, thankfully, is delaying middle school and high school
start times. I'm not sharing data here this morning, but you should know that times have
gotten earlier and earlier since the early 1980s, and there is data to suggest that and
a number of theories about it.
One has to do with bus schedules. Another has to do with growth of sort of suburbia
and kind of urban sprawl. Another has to do with ... that you would find fascinating as
high school teachers, and that's the push from public school teachers in the United
States back in, again, the late '70s and into the 1980s for salary needs. And in some states,
they're not being met, and so teachers are arguing that they need to have a second job,
and so high schools teachers wanting schools to start earlier so that they could have a
second job. There's been some discussion about that, but they seemed to be here to stay.
That's the story: school start times. With the exception of the districts that are working
hard to delay school start times, in terms of the historical data, have gotten earlier
and earlier since the 1980s. There are a number of conversations going on. I'm sorry.
Employment hours is an interesting discussion; drivers education programs. So, all of these
- regulation of caffeine as I'm suggesting - are larger policy-related systematic countermeasures.
I don't want you to forget the bottom part of this slide. I think it's a two-pronged
multi-tiered approach. And that is to say we also need to be thinking about preventive
intervention programs, education, and what you all can be doing in high schools or in
middle schools, in psychology classes, in biology classes, and in health classes if
you're in a district that still teaches health. In other words, sleep has to be included in
the curriculum, and not just at a didactic level but at a personal level.
And that's why I'm very much in favor of you doing activities or exercises or assignments
with your students to get your students to think about change at the individual level
and policy change. We all know that if we take an interactive approach, we're more likely
to say, whoa, I just collected sleep-wake diary information on my own sleep-wake patterns.
Now I see what's going on. And one is more likely to then use that to change behavior.
That will be a whole another discussion, but I've been doing some of that with the Worcester
public schools.
So what do we know about this research on the actual intervention studies that have
been done where districts have systematically changed school start times? And I've sort
of put all ... there are now quite a number of studies. You can really do a review paper
now on this area, finally. And in fact, a colleague of mine has just done that, and
it will be part of a book chapter, demonstrating that delaying school start times has a positive
impact both in terms of the amount of sleep, timing of sleep, obviously, and then secondary
implications for academic performance, behavior, and mood, and so on.
So, a number of studies have compared school start times, for example, 7:30 AM versus 8:30
AM. They are largely convenient samples. Most of them have been self-reported sleep-wake
patterns. A few using actigraphy. A number of the studies have looked at transcript,
academic grades, as well as self-reported grades, self-reported emotional well-being.
And the general findings are, first of all, adolescents do not stay up later and later.
In other words, when you delay school start time, when you go from 7:30 to 8:30, it does
not mean that the adolescent then goes to bed at 1:00 instead of midnight or 11:00.
They don't do that. So what happens is for the most part, they gain the amount of sleep
that you've allowed for by shifting what time they have to be in school. It's really beautiful.
I mean people really, myself included, kind of said, oh my goodness, with all the things
that kids can do, are they just going to stay up later? Do some kids stay up later? Yes.
But on average, it's 40 to 60 minutes that you increased the amount of sleep. Clinically
speaking, it only is about 15 to 20 minutes of sleep that can make a difference. So this
is much larger than that, regardless of statistical significance.
But not only that, but some studies are showing - I can't say there's a study that shows exactly
what hour of the day - improved academic performance. Our study that we did here in the Worcester
public schools, we were not able to show statistical significance for seventh graders but eighth
graders were able to demonstrate improved academic performance on transcript grades.
And also, most of the studies report decreased tardiness, which we all know kids who are
more tardy tend to do less well in school. In our dataset, four times less tardiness
after we delayed school start times.
And then also, some of the other secondary variables in Judith Owens' study that was
done in a private school setting: lower levels of depressed mood, and, overall, teachers
and students being satisfied with delaying school start times.
This is just one of our studies. Okay.
So, we're going to have some fun. So first of all, I hope we have enough.
>>WORKSHOP PARTICIPANT: [Unclear] technically, we should have finished by 10:00.
>>WOLFSON: Oh, geez. I was thinking 10:30. Oh my god, okay. Well, I'll just describe
what I think you can do with your students, okay? I'll just describe. We won't actually
do the whole exercise but you can take it back with you. This happens to me, I apologize.
I guess in my head, I was thinking 10:30. I don't know why. That's so strange. Even
though we said 90 minutes, I start looking at the clock.
So first of all, what I'm going to do, and you can do it with your students, is I hand
out a little piece of paper, not blank, which I turn over, and it has a role. So you pretend
that you're the student. You can just pass these back. Just someone pass them out. I
hope we have enough. But you'll see there are different roles. And then what you can
also pass out, if someone else can just pass these out? Everyone should take one of those.
So I present to you that, okay, you've now been educated. You've done your homework.
Either you are a sleep researcher, or you're a superintendent of schools, or you're an
assistant superintendent, you're a principal of an elementary school, a middle school,
a high school, you might be a member of your school district's school start time change
committee. You're on this committee, you're a rebel-rouser. You've agreed to be on this
committee. You're a parent of a kindergartener, you're a parent of a third grader, you're
a parent of a tenth grader, you're a parent of an early adolescent, a seventh grader,
you're a high school teacher, you're a middle school teacher at a school that starts early
in the morning, or you're a middle school teacher because in the district you live in,
a few middle schools already start later, or you're an elementary school age teacher,
or you might be a hockey coach, a football coach, a swimming coach. You're an eighth
grader yourself, eleventh grader. You're a representative from the National Sleep Foundation
who's coming to give a talk to your school district. Or you're a journalist. You're in
there in the media and you would like to talk about this story throughout your state nationally
or just in the school that's as I call this project, Sleepy Town U.S.A.
So what I tell the students ... you can imagine this. We won't actually break into groups,
but you can sort of go through it and you imagine what it would be like. What I have
the students do is I first have them get into groups, and I create the groups. Generally,
we'll have sort of a group that ... where do I have this list? Oh yeah, sorry. I break
you into three groups. One group is what I consider sort of the expert group that's gotten
together. It's the school start time committee of the school district, and the school start
time committee has brought in different experts who advise them and help them do their homework
on the issue of adolescent sleep and whether or not the district should change school start
times.
Group number two are school professionals, so they're the teachers and the coaches who
have their own little committee who is getting together. They know this school start time
committee is going on in the district, but they're meeting after school to talk about
it; how they feel about it and when they want to go with this.
And then often, some kind of PTA or parent committee.
And I give the students some time to role play being in those groups for a little while,
not long, 5 to 10 minutes or so. And then I have everybody come back together for a
town hall meeting. And the job of the town hall meeting is for each group ... first with
the school start time committee presenting its recommendations. I generally give the
recommendations so they know what they're moving towards. So in this case, their recommendation
is that elementary schools change to a certain degree, middle schools change, and high schools
change. Other times, I've done it without any planned recommendations.
And then there's a discussion, as if it's real life. This is how the school districts
are doing this often - town hall meeting style to talk about, are they going to go with the
recommendations? What do they want the school board to do? It's a great way to get your
students to see the, to go from the research that you've been talking about in class to
talking about the research themselves from different perspectives. And the assumption
is that each of these groups has some access to the information, obviously.
And how a different perspective ... if a parent of a second grader comes in to this, if you're
a parent of a second grader and it's your oldest child and you haven't had any adolescents
yet, and the recommendation is that elementary schools is now going to start earlier in the
morning in order to accommodate the middle schools and high schools. Most parents of
second graders and the students, the high school students and college get this right
away ... are often furious. They don't want this for some reason. Or the story of the
hockey coach who wants to have kids in practice early in the morning, or the football coach
who wants lit fields and is upset unless the school district is going to purchase lights
to allow the kids to practice starting later if it means the northeast and it's going to
get dark too early in the fall. The football coach is adamantly opposed to changing school
start times, regardless of what it does for his or her football players' academic performance
and so on.
I am stereotyping a little bit, but just that the students fall into those role plays immediately.
You would make the time to do it, and you sort of let that evolve. Sometimes they get
involved, sometimes they don't, and it allows for a real discussion of the relationship
between research, theoretical understanding of these issues that we were talking about
all morning, and then real-life implications.
And so I know that we don't have time to do that exercise. It's pretty straightforward
and you can do it on your own. So I think we'll end with that. I guess if you have five
minutes to do the Q & A. Does that work for your schedule?
>>WORKSHOP PARTICIPANT: Thank you.