sleep and student performance at school
TRANSCRIPT
Sleep and Student Performance at School Howard Taras, Will iam Potts-Datema
ABSTRACT: To review the state of research on the association between sleep among school-aged children and academic outcomes, the authors reviewed published studies investigating sleep, school performance, and cognitive and achievement tests. Tables with brief descriptions of each study’s research methods and outcomes are included. Research reveals a high prevalence among school-aged children of suboptimal amounts of sleep and poor sleep quality. Research demonstrates that suboptimal sleep affects how well students are able to learn and how it may adversely affect school perjormance. Recommendations for further research are discussed. (J Sch Health. 2005;75(7):248-254)
ealth professionals frequently remind educators of H the correlation between healthy behaviors and educa- tional outcomes. However, evidence for this connection is not always apparent or readily available. The increasing emphasis on accountability for schools has amplified the importance of demonstrating connections between stu- dents’ health and their academic performance. An under- standing of the impact of student health on educational outcomes has major implications. Among them are rami- fications for how schools address health concerns, such as the focus of their school health programs.
The National Coordinating Committee on School Health and Safety (NCCSHS), comprising representatives of several federal departments and national nongovem- mental organizations, encourages school districts to respond to evolving challenges by developing coordinated school health programs. To enhance awareness of existing evidence linking health and school performance and to identify gaps in knowledge, the NCCSHS is reviewing the state of research in related areas. The project involves a literature search of peer-reviewed, published research reporting on the relationship between students’ health and their performance in school. Compilations of research articles that explore the association between academic performance and health include various chronic conditions (eg, asthma, diabetes), nutrition, and physical activity. This article summarizes what is known on the association of sleep with academic outcomes among school-aged children.
BACKGROUND ON SLEEP Most children need at least 9 hours of restful sleep
each night. I However, for many reasons, school-aged chil- dren may receive less than the recommended number of hours of sleep. These reasons include the working, eating, and bedtime patterns of students and their families, early school start times, and childhood sleep disorders such as disrupted sleep from snoring or breathing pauses. A num- ber of research articles have reported on the prevalence of
Howard Taras, MD, Pmfessol; ([email protected]). Division of Community Pediutncs, University of California, San Diego, Gilman Drive #0927, LA Jolla, CA 92093-0927; and William Poas-Datema, MS, Directol; (wpottsda C3hsph.harvard.edr.i). Partnerships for Children’s Health, Harvard School of Public Health, 677 Huntington Ave. 7th Flool; Boston, MA 021 15. This article is 1 of 6 articles that are part of a project of the Narioiml Coor- dinating Committee on School Health and Safety (NCCSHS). This NCCSHS project w m funded by the US Department of Health and Human Services, Department of Education, and US Department of Agriculture. Opinions ex- pressed in this article are not necessarily shared by these federal agencies or other institutions that comprise NCCSHS membership.
suboptimal sleep in school-aged children and the associa- tion of quality and quantity of sleep with school perfor- mance and measures of cognitive ability.
SELECTION OF SLEEP ARTICLES Only articles meeting the following criteria were
selected for review: (1) study subjects were school-aged children (5-18 years); (2) the article was published in the past 10 years (1994-2004) in a peer-reviewed journal; and (3) the research included at least 1 of the following outcomes-school attendance, academic achievement, a measure of cognitive ability (such as general intelligence, memory), and attention. The outcome of students’ level of attention was acceptable only if measured objectively. Studies were identified using MedLine and similar Inter- net-based searches. If a full article could not be retrieved, studies with detailed abstracts were included. Many stud- ies cited in this review had major outcome measures other than those pertinent to the objectives of this project. These alternative outcomes may not be described at all or are briefly mentioned.
LITERATURE REVIEW Investigators are attempting to answer several ques-
tions: How much sleep are students getting? Do inade- quate amounts or quality of sleep affect educational outcomes or cognitive performance? What is the effect of sleep-disordered breathing on students? Is daytime sleepi- ness associated with school performance?
Tables 1-3 contain lists of articles on sleep that met the inclusion criteria. A brief description of the experimental design and the outcome also is included for each. Table 1 lists general articles on sleep in school-aged children.
The largest number of articles studied sleep disorders and sleep habits and patterns, particularly among adoles- cents. Many studies on sleep disorders are on sleep-disor- dered breathing. Most are relatively recent and include control groups. Research findings appear to be relatively consistent, although outcome measures differ. An excel- lent review by Blunden et a12 in 2001 of 13 articles dem- onstrated that reduced attention, memory, intelligence, and increased problematic behavior resulted from sleep-related obstructive breathing. With the exception of 1 study in this review, children in all studies improved in neurocognitive, behavioral, and/or school performance after an adenoid- tonsillectomy. Articles listed in Table2 are those not re- viewed by Blunden et al that investigate the same issues. Like the conclusions of Blunden et al, the findings of these studies raise concern because of the high prevalence of
248 Journal of School Health September 2005, Vol. 75, No.7
sleep-disordered breathing among elementary school student populations. Most articles demonstrate an effect on neuro- cognitive ability. Fewer demonstrate effects on academic performance. I t i s encouraging that academic achievement among children with disordered breathing improves after corrective measures are taken, such as surgery or tonsillec- tomy/adenoidectomy. If minor sleep disorders, such as snor- ing, can be identified and managed prior to or during the school-age years, significant improvement in educational outcomes may ensue.
Table 3 lists published research that investigates sleep patterns among children and adolescents. The research findings raise several important issues for educators. The onset of adolescence appears to be accompanied by a decrease in sleep in a 24-hour period among many youth at this stage of l ife. The academic consequences of these changes in sleep habits are inconclusive. Data collection in studies performed to date i s based more on surveillance
of parents, teachers, or students-a methods that requires some level of validation.
Some school districts have pushed back school start times for adolescents, and the issue of school starting times i s widely debated among parents of adolescents and school ad- ministrators. Unfortunately, published peer-reviewed studies that investigate the benefits of such modifications are virtu- ally absent in the literature. Experimental conditions of sleep restriction and deprivation appear to impair neuropsycholog- ical performance related to higher-level cognitive functions and attention. But reversal of this through changed school start times has yet to be proven.
An excellent article by Fallone et a13 reviewed many of the studies included in this collection and concluded that varying definitions of “good” versus “poor” sleep limit the ability to compare studies. A review of the literature was performed by Wolfson and Carskadon4 in 2003. These reviewers noted that a majority of studies in this field rely
Table 1 General Articles on Sleep in School-Aged Children
Reference (Origin) Experimental Design Outcome
Eliasson A, Eliasson A, King J, Gould B, Eliasson A. Association of sleep and academic performance. Sleep Breath. 2002;6(1):45-48. (United States)
Kahn A, Van de Merckt C, Rebuffat E, et al. Sleep problems in healthy preadolescents. Pediafrics.
(Belgium) 1989;84(3):542-546.
Link SC, Ancoli-Israel S. Sleep and the teenager. Sleep Res. 1995;24A:184. (United States)
Meijer AM, Habekothe HT, Van Den Wittenboer GL. Time in bed, quality of sleep and school functioning of children. J Sleep Res.
(Netherlands) 2000;9(2):145-153.
Teachers administered a I-page questionnaire to 1000 students in 9th through 12th grades in a number of schools in 1 community as well as to 200 7th graders. Self-reported Grade Point Average (GPA) included in questionnaire.
children completed questionnaires about their own and their children’s sleeping habits and schooling.
Parents of 972 3rd- to 5th-grade
150 high school students (mean age 16 years) were given a questionnaire that included sleep questions and GPA.
449 students (9-14 years) responded to classroom questionnaires, including Bourdon-Vos pencil/paper test measured attention, School Perception Questionnaire of school functioning, and a sleep questionnaire. Study also controlled for psychosomatic and neurotic complaints that could influence the association between sleep and school functioning (using a standardized questionnaire measuring these characteristics).
90% of students feel groggy at school from sleepiness, 40% very groggy. Average sleep time 6.7 hourshight on weekdays (7.7 on weekends). No correlation between sleep time and academic performance in any grade.
Sleep difficulties lasting more than 6 months were present in 43% of children. Among the 132 poor sleepers, 21% failed 1 or more years of school-a significantly higher percentage than found among those without sleep problems. 28% expressed a desire for counseling.
High GPA correlated significantly with waking up later on school days, early rising on weekends, less time taken to fall asleep, fewer night awakenings, and fewer daytime naps on school days.
15% report sleep problems, 43% have difficulty getting up in the morning, and 25% do not feel rested at school. Regression analyses demonstrated that although sleep characteristics do not have an impact on concentration, they do have a significant impact on some aspects of school functioning, in particular, children’s motivation to achieve in school.
Journal of School Health September 2005, Vol. 75, No.7 249
Tabl
e 2
Art
icle
s on
Dis
ord
ered
Sle
ep (C
ontin
ued
on n
ext p
age)
Ref
eren
ce (O
rig
in)
Ali
NJ,
Pits
on D
, Stra
dlin
g JR
. Sle
ep d
isor
dere
d br
eath
ing:
effe
cts
of a
deno
-tons
illect
omy
on
beha
vior
and
psy
chol
ogic
al fu
nctio
ning
. Eu
rJ
Ped
iatr.
1996;i 5556-62.
(Uni
ted
Kin
gdom
)
And
reou
G, K
arap
etsa
s A,
Aga
pito
u P,
G
ourg
oulia
nis
K. V
erba
l int
ellig
ence
and
sle
ep
diso
rder
s in
chi
ldre
n w
ith A
DH
D. P
erce
pt M
ot
Skill
s. 2003;96(3 P
t 2):1283-1288.
(Gre
ece)
Blu
nden
S, L
ushi
ngto
n K,
Ken
nedy
D, M
artin
J,
Daw
son
D. B
ehav
ior a
nd n
euro
cogn
itive
pe
rform
ance
in c
hild
ren
aged
5-1 0
year
s w
ho
snor
e co
mpa
red
to c
ontro
ls. J
Clin
fxp
N
euro
psyc
h. 2000;22( 5): 554-568.
(Aus
tralia
)
Che
rvin
RD
, Cla
rke
DF,
Hof
fman
JL. S
choo
l pe
rform
ance
, rac
e, a
nd o
ther
cor
rela
tes
of
slee
p-di
sord
ered
bre
athi
ng in
chi
ldre
n. S
leep
(Uni
ted
Sta
tes)
M
ed. 2003;4:21-27.
Exp
erim
enta
l Des
ign
33 c
hild
ren (6-1 2 ye
ars)
who
sno
red
and
wer
e on
a w
aitin
g lis
t for
hav
ing
thei
r ade
noid
s an
d to
nsils
rem
oved
wer
e vi
site
d at
hom
e an
d m
onito
red
durin
g sl
eep
with
a v
ideo
and
ox
imet
ry (m
easu
re o
f air
exch
ange
and
ox
ygen
atio
n). O
f the
se, 12
had
evid
ence
of
slee
p di
stur
banc
e se
cond
ary
to a
irway
ob
stru
ctio
n an
d 11
of t
hose
rem
aini
ng o
n th
e w
aitin
g lis
t wer
e m
atch
ed b
y ag
e an
d se
x w
ith
the 12. A
noth
er 10
cont
rol c
hild
ren
wer
e st
udie
d as
wel
l. A
ll ch
ildre
n w
ere
stud
ied
for
inte
lligen
ce (W
ISC
-R),
atte
ntio
n (c
ontin
uous
pe
rform
ance
test
), an
d te
sts
of im
puls
ivity
and
be
havi
or w
ere
perfo
rmed
bef
ore
surg
ery
and
3-6 m
onth
s af
ter s
urge
ry.
18 c
hild
ren (8-13 y
ears
) with
AD
HD
wer
e m
atch
ed w
ith 18
age-
and
sex
-mat
ched
co
ntro
l chi
ldre
n. M
easu
res
wer
e A
DH
D
asse
ssm
ents
, fiv
e ve
rbal
sca
les
of th
e W
ISC
- Ill (
inte
llige
nce s
cale
), an
d po
lyso
mno
grap
hic
stud
ies
of s
leep
. 16
child
ren
refe
rred
to E
NT/
pulm
onar
y cl
inic
for
snor
ing
eval
uatio
n (m
ean
age
7.2)
. Mat
ched
w
ith 16
cont
rols
for a
ge a
nd s
ex. W
lSC
(an
d W
PP
SI-R
for p
resc
hool
ers)
, WR
AM
L,
Aud
itory
Con
tinuo
us P
erfo
rman
ce T
est a
nd
Chi
ld B
ehav
ior C
heck
list m
easu
red
inte
lligen
ce, m
emor
y an
d le
arni
ng, a
ttent
ion
and
beha
vior
. Sle
ep m
easu
red
usin
g pa
rent
s’
7-da
y sl
eep
log,
pol
ysom
nogr
aphy
, and
a
slee
p di
stur
banc
e sc
ale.
S
tude
nts
in 2
nd a
nd 5
th g
rade
s in
1 sc
hool
di
stric
t rec
ruite
d by
sen
ding
lette
rs h
ome.
S
leep
-dis
orde
red
brea
thin
g was
mea
sure
d us
ing
a va
lidat
ed p
aren
t que
stio
nnai
re. S
choo
l pe
rform
ance
was
mea
sure
d us
ing
teac
hers
’ ra
tings
(5-p
oint
scal
e) a
nd y
ear-
end
Rea
ding
an
d M
ath
asse
ssm
ents
.
Out
com
e
Chi
ldre
n w
ith s
leep
-dis
orde
red
brea
thin
g im
prov
ed in
agg
ress
ion,
inat
tent
ion,
hy
pera
ctiv
ity, a
nd v
igila
nce
afte
r sur
gery
, but
no
t on
inte
lligen
ce. T
he o
ther
2 gr
oups
did
not
ch
ange
on
pre-
and
pos
ttest
s, o
r cha
nged
for
only
hyp
erac
tive
beha
vior
and
vig
ilanc
e.
Poo
r qua
lity
of s
leep
was
foun
d on
chi
ldre
n w
ith
AD
HD
(apn
ea, d
esat
urat
ed h
emog
lobi
n, a
nd
awak
enin
gs a
ssoc
iate
d w
ith li
mb
activ
ity a
nd
snor
ing)
. The
se c
hild
ren
had
low
per
form
ance
(o
f up
to 20
poin
ts) o
n th
e W
ISC
-Ill v
erba
l sc
ores
. C
ompa
red
to c
ontro
ls, c
hild
ren
who
sno
red
(but
who
did
not
nec
essa
rily
have
obs
truct
ive
slee
p ap
nea)
sho
wed
sig
nific
antly
impa
ired
atte
ntio
n, lo
wer
mem
ory
and
inte
lligen
ce
scor
es (a
lthou
gh m
emor
y an
d in
tellig
ence
w
ere
with
in n
orm
al ra
nge)
. Mild
slee
p-
diso
rder
ed b
reat
hing
affe
cted
day
time
func
tioni
ng.
146
pare
nts
com
plet
ed th
e qu
estio
nnai
res
on
thei
r chi
ldre
n. S
leep
-dis
orde
red
brea
thin
g w
as
asso
ciat
ed w
ith p
oor t
each
er r
atin
g. S
leep
- di
sord
ered
bre
athi
ng w
as n
ot s
igni
fican
tly
asso
ciat
ed w
ith R
eadi
ng o
r Mat
h as
sess
men
t sc
ores
.
Tabl
e 2
Art
icle
s on D
isor
dere
d Sl
eep
(Con
tinue
d fr
om p
revi
ou
s pa
ge)
Ref
eren
ce (O
rigi
n)
Exp
erim
enta
l Des
ign
Out
com
e
Goz
al D
. Sle
ep-d
isor
dere
d br
eath
ing
and
scho
ol
perfo
rman
ce in
chi
ldre
n. P
edia
trics
.
(Uni
ted
Sta
tes)
19
98:1
02(3
);616
-620
.
1 st-g
rade
child
ren
rank
ed in
the
low
est 1
0th
perc
entil
e of
cla
ss w
ere
iden
tifie
d (2
97).
Par
ents
com
plet
ed a
que
stio
nnai
re on
ob
stru
ctiv
e sl
eep
apne
a; c
hild
ren
rece
ived
ov
erni
ght r
ecor
ding
s of s
leep
and
resp
irato
ry
func
tiodg
as e
xcha
nge
at n
ight
. Par
ents
of
child
ren
with
abn
orm
al r
esul
ts w
ere
enco
urag
ed to
see
k su
rgic
al c
orre
ctio
n.
Sch
ools
pro
vide
d ac
adem
ic g
rade
s for
2
succ
essi
ve ye
ars.
Ow
ens
J, S
pirit
0 A,
Mar
cotte
A, M
cGui
nn M
, B
erke
lham
mer
L. N
euro
psyc
holo
gica
l and
be
havi
oral
corr
elat
es o
f obs
truct
ive
slee
p ap
nea
synd
rom
e in
chi
ldre
n: a
pre
limin
ary
stud
y. S
leep
Bre
ath.
200
0;4(
2):6
7-77
. (U
nite
d S
tate
s)
Rob
erts
RE
, Rob
erts
CR
, Che
n LG
. Fun
ctio
ning
of
ado
lesc
ents
with
sym
ptom
s of
dis
turb
ed
slee
p. J
You
th A
dole
sc. 2
001 ;
30: 1
-1 8.
(Uni
ted
Sta
tes)
18 c
hild
ren
(age
7.3
yea
rs) w
ith o
bstru
ctiv
e sl
eep
apne
a w
ere
test
ed fo
r a n
umbe
r of
neur
opsy
chol
ogic
func
tions
: gen
eral
cog
nitiv
e fu
nctio
ning
(McC
arth
y S
cale
s); l
angu
age
(Pea
body
Pic
ture
Voc
abul
ary)
; exe
cutiv
e fu
nctio
ning
, suc
h as
pla
nnin
g an
d or
gani
zatio
n: a
nd a
ttent
ion,
mem
ory
(Mem
ory
Sca
le o
f McC
arth
y S
cale
), an
d vi
sual
pe
rcep
tion a
nd v
isua
l mot
or in
tegr
atio
n. M
otor
an
d be
havi
oral
mea
sure
s (p
aren
t rat
ings
) w
ere
also
con
duct
ed. E
ight
chi
ldre
n w
ho
rece
ived
an
aden
oid-
tons
illec
tom
y wer
e re
eval
uate
d.
Dat
a fro
m a
larg
e sc
hool
-bas
ed su
rvey
of 5
423
stud
ents
(gr
ades
6-8
) wer
e us
ed to
exa
min
e th
e as
soci
atio
n be
twee
n le
vels
of f
unct
ioni
ng
and
sym
ptom
s of
inso
mni
a (a
per
iod
of a
t le
ast 2
wee
ks o
f hav
ing
troub
le fa
lling
asl
eep,
st
ayin
g as
leep
, or a
wak
enin
g to
o ea
rly) a
nd
‘hyp
erso
mni
a” (
at le
ast 2
wee
ks o
f sle
epin
g to
o m
uch)
.
Gas
exc
hang
e di
fficu
lty, i
ndic
ativ
e of
obs
truct
ive
slee
p ap
nea,
occ
urre
d fre
quen
tly a
mon
g 1 s
t gr
ader
s w
ith a
cade
mic
diff
icul
ty (1
8%).
Tho
se
with
gas
exc
hang
e pr
oble
ms w
ho r
ecei
ved
a to
nsill
ecto
my/
aden
oide
ctom
y sig
nific
antly
im
prov
ed th
eir g
rade
s (2
.4-2
.9) t
he fo
llow
ing
year
, whe
reas
thos
e el
ectin
g no
t to
get
reco
mm
ende
d su
rger
y ha
d no
sig
nific
ant
incr
ease
. No
acad
emic
impr
ovem
ents
oc
curr
ed in
thos
e w
ithou
t evi
denc
e of
obs
truct
ive
slee
p ap
nea.
atte
ntio
n, a
nd m
otor
ski
lls w
ere
foun
d. T
here
w
as li
ttle
corr
elat
ion
betw
een
the
seve
rity
of
the
obst
ruct
ive
slee
p ap
nea
(as
mea
sure
d by
A
pnea
Hyp
opne
a In
dex)
and
the
leve
l of
func
tioni
ng. T
ests
did
not
sig
nific
antly
impr
ove
afte
r sur
gery
, alth
ough
som
e ap
proa
ched
st
atis
tical
sig
nific
ance
for
impr
ovem
ent.
Mod
est i
mpa
irmen
ts in
exe
cutiv
e fu
nctio
ning
,
App
roxi
mat
ely
6%, 1
2%, a
nd 3
% o
f stu
dent
po
pula
tion
repo
rted
hype
rsom
nia
only
, in
som
nia
only
, and
bot
h (r
espe
ctiv
ely)
. Usi
ng
thos
e w
ithou
t sle
ep p
robl
ems
as a
refe
renc
e gr
oup
and
logi
stic
regr
essi
on an
alys
is, t
he
auth
ors
foun
d th
at re
porte
d ab
senc
e du
e to
ill
ness
was
sig
nific
antly
incr
ease
d am
ong
stud
ents
who
had
inso
mni
a an
d th
ose
with
bo
th h
yper
som
nia
and
inso
mni
a.
AD
HD
, Atte
ntio
n D
efic
iVH
yper
activ
ity D
isor
der;
WIS
C-I
ll, W
echs
ler
Inte
llige
nce S
cale
for
Chi
ldre
n-Th
ird
Edi
tion;
WIS
C-R
, Wec
hsle
r In
telli
genc
e Sca
le fo
r Chi
ldre
n-R
evis
ed;
WP
PS
I-R, W
echs
ler P
resc
hool
and
Prim
ary
Sca
le-R
evis
ed;
WR
AM
L, W
ide
Ran
ge A
sses
smen
t of M
emor
y an
d Le
arni
ng-S
econ
d E
ditio
n.
N
tJl
N
Tabl
e 3
Art
icle
s on
Sle
ep H
abits
an
d S
leep
Dep
riva
tion
(Co
nti
nu
ed
on
ne
xt p
age)
Ref
eren
ce (O
rig
in)
Exp
erim
enta
l Des
ign
Out
com
e
Alle
n R
P. S
ocia
l fact
ors
asso
ciat
ed w
ith th
e am
ount
of
scho
ol w
eek
slee
p la
g fo
r sen
iors
in a
n ea
rly s
tarti
ng
subu
rban
hig
h sc
hool
. Sle
ep R
es. 1
992;
21:1
14.
(Uni
ted
Sta
tes)
Dra
ke C
, Nic
kel C
, Bur
duva
li E, R
oth
T, J
effe
rson
C,
Pie
tro B
. The
ped
iatri
c day
time
slee
pine
ss sc
ale
(PD
SS
): sl
eep
habi
ts a
nd s
choo
l out
com
es. S
leep
.
(Uni
ted
Sta
tes)
effe
cts
on d
aytim
e fu
nctio
ning
of fi
fth-g
rade
child
ren
in
Isra
el. S
leep
. 199
8;21
(3):2
50-2
56.
(Isra
el)
2003
;26(
4):4
55-4
58.
Eps
tein
R, C
hilla
g N
, Lav
ie P
. Sta
rting
times
of s
choo
l:
Fallo
ne G
, Ace
bo C
, Arn
edt J
T, S
eife
r R, C
arsk
adon
MA
. E
ffect
s of a
cute
sle
ep re
stric
tion o
n be
havi
or, s
usta
ined
at
tent
ion,
and
resp
onse
inhi
bitio
n in
chi
ldre
n. P
erce
pt
(Uni
ted
Sta
tes)
M
ot S
kills
. 200
1 ;93
:213
-229
.
Fred
rikse
n K, R
hode
s J,
Red
dy R
, Way
N. S
leep
less
in
Chi
cago
: tra
ckin
g th
e ef
fect
s of
ado
lesc
ent s
leep
loss
du
ring
the
mid
dle
scho
ol y
ears
. Chi
ld D
ev.
(Uni
ted
Sta
tes)
20
04;7
5( 1
):84-
95.
All s
tude
nts a
ttend
ing
12th
gra
de in
a h
uman
beh
avio
r cl
ass
in 1
‘ear
ly s
tarti
ng” s
choo
l (7:
40 A
M) w
ere
surv
eyed
anon
ymou
sly
for s
leep
pat
tern
s, p
arty
ing
habi
ts, g
rade
s, a
lcoh
ol co
nsum
ptio
n, a
nd o
ther
hab
its.
450
stud
ents
(age
11 -
1 5) r
espo
nded
to a
writ
ten
surv
ey o
f sl
eep
and
scho
ol a
chie
vem
ent a
nd s
leep
ines
s.
5th-
grad
e pu
pils
(1 0-
12 ye
ars
old)
from
28
clas
ses
in
18 sc
hool
s th
roug
hout
Isra
el w
ere
divi
ded
into
“ear
ly
riser
s” (N
= 2
32),
who
sta
rted
scho
ol a
t 7:lO
AM
(42%
) at
leas
t 2 ti
mes
a w
eek,
and
“reg
ular
rise
rs” (
N =
340),
who
alw
ays
star
ted
scho
ol a
t 8:O
O AM
(58%
). C
hild
ren
com
plet
ed se
lf-ad
min
iste
red q
uest
ionn
aire
s con
cern
ing
slee
p ha
bits
dur
ing
scho
ol d
ays,
wee
kend
s, a
nd
holid
ays,
day
time
fatig
ue, s
leep
ines
s, a
nd d
iffic
ultie
s co
ncen
tratin
g and
pay
ing
atte
ntio
n in
sch
ool.
82 c
hild
ren
(age
8-1
5) c
ompl
eted
5 n
ight
s of
bas
elin
e sl
eep
and
then
rand
omly
ass
igne
d to
opt
imiz
ed (1
0 ho
urs)
or r
estri
cted
(4 h
ours
) sle
ep in
an
over
nigh
t lab.
B
ehav
ior,
Per
form
ance
, and
sle
epin
ess w
ere
asse
ssed
th
e fo
llow
ing
day.
Stu
dent
s re
porte
d sl
eepi
ness
and
wer
e gi
ven
seve
ral o
bser
vatio
n m
easu
res
of
atte
ntiv
enes
s.
2259
stu
dent
s (a
ge 1
0 th
roug
h 14
ove
r the
cou
rse
of th
e st
udy)
wer
e gi
ven
a su
rvey
ann
ually
for 3
con
secu
tive
year
s by
thei
r mid
dle
scho
ol te
ache
r. S
leep
, dep
ress
ive
sym
ptom
s, s
elf-e
stee
m, a
nd a
cade
mic
out
com
es w
ere
self-
repo
rted b
y th
e st
uden
ts. A
sta
tistic
al m
odel
was
us
ed to
det
erm
ine
whe
ther
few
er h
ours
of s
leep
cau
sed
poor
gra
des,
low
er s
elf-e
stee
m, a
nd d
epre
ssiv
e affe
ct
or w
heth
er th
ese
caus
ed p
oor s
leep
.
Thos
e st
uden
ts w
ho w
ent t
o be
d la
ter o
n w
eeke
nds
(ie, t
hey
did
not “
catc
h up
” on
slee
p lo
st d
urin
g th
e w
eek
as a
resu
lt of
an
early
sta
rt) h
ad p
oore
r gra
des.
A
usu
al w
eeke
nd b
edtim
e af
ter 2
:30
AM w
as re
porte
d by
15%
of s
tude
nts w
ith A
and
B+
gra
des,
and
35%
of
thos
e re
porti
ng av
erag
e gr
ades
. S
igni
fican
t line
ar re
latio
nshi
ps fo
und
betw
een
slee
p tim
e an
d da
ytim
e sl
eepi
ness
. Sig
nific
ant li
near
rela
tions
hips
fo
und
betw
een
dayt
ime
slee
pine
ss a
nd s
choo
l ac
hiev
emen
t. S
leep
ines
s ac
ross
gra
de le
vels
indi
cate
d th
at s
leep
ines
s inc
reas
ed si
gnifi
cant
ly w
ith g
rade
leve
l. M
ean
slee
p tim
e of
the
“ear
ly ri
sers
” was
sig
nific
antly
sh
orte
r tha
n th
at o
f the
‘reg
ular
ris
ers.
” E
arly
rise
rs
com
plai
ned
sign
ifica
ntly
mor
e ab
out d
aytim
e fa
tigue
an
d sl
eepi
ness
, and
abo
ut a
ttent
ion
and
conc
entra
tion
diffi
culti
es in
sch
ool.
Thei
r com
plai
nts w
ere
inde
pend
ent o
f the
repo
rted
hour
s of
sle
ep.
Alth
ough
sle
ep re
stric
tion
was
ass
ocia
ted w
ith in
crea
sed
child
repo
rts o
f sle
epin
ess a
nd in
atte
ntiv
e be
havi
ors,
th
ere
was
no
sign
ifica
nt im
paire
d pe
rform
ance
on te
sts
of r
espo
nse
inhi
bitio
n an
d of
sus
tain
ed a
ttent
ion.
Girl
s in
itial
ly re
porte
d m
ore
slee
p th
an b
oys,
yet
rep
orte
d a
shar
per d
eclin
e ov
er th
e co
urse
of 3
yea
rs th
an b
oys.
G
irls
repo
rted
high
er g
rade
s th
an b
oys
initi
ally
and
ove
r th
e 3
year
s. S
tude
nts
who
initi
ally
repo
rted
high
er
leve
ls o
f sle
ep a
lso
tend
ed to
repo
rt hi
gher
gra
des.
The
ra
te o
f cha
nge
in h
ours
of s
leep
ove
r the
3 y
ears
was
no
t sig
nific
antly
ass
ocia
ted w
ith th
eir g
rade
s. G
rade
s (a
nd e
stee
m a
nd a
ffect
) wer
e in
fluen
ced
by s
leep
, not
vi
ce v
ersa
.
Tabl
e 3
Art
icle
s on
Sle
ep H
abits
and
Sle
ep D
epri
vatio
n (C
onti
nued
fro
m p
revi
ou
s p
age)
Ref
eren
ce (O
rigi
n)
Exp
erim
enta
l Des
ign
Ou
tco
me
Gia
nnot
ti F,
Cor
tesi
F, S
ebas
tiani
T, O
ttavi
ano
S.
Circ
adia
n pr
efer
ence
, sle
ep a
nd d
aytim
e be
havi
our i
n ad
oles
cenc
e. J
Sle
ep R
es. 2
002;
11(3
):191
-199
. (It
aly)
Ran
dazz
o A
C, M
uehl
bach
MJ,
Sch
wei
tzer
PK
, Wal
sh J
K.
Cog
nitiv
e fu
nctio
n fo
llow
ing
acut
e sl
eep
rest
rictio
n in
child
ren
ages
10-
14. S
leep
. 199
8;21
:861
-868
. (U
nite
d S
tate
s)
Sad
eh A
, Gru
ber R
, Rav
iv A
. The
effe
cts
of s
leep
re
stric
tion a
nd e
xten
sion
on
scho
ol-a
ge ch
ildre
n.
Chi
ld D
ev. 2
003;
74:4
44-4
55.
(Isra
el)
Shi
n C
, Kim
J, L
ee S
, Ahn
Y, J
oo S
. Sle
ep h
abits
, ex
cess
ive
dayt
ime
slee
pine
ss a
nd s
choo
l per
form
ance
in
hig
h sc
hool
stu
dent
s. P
sych
iatry
Clin
Neu
rosc
i.
(Sou
th K
orea
) 20
03;5
7(4)
:451
-453
.
Ove
r 660
0 ad
oles
cent
s (ag
e 14
-1 8)
com
plet
ed
a co
mpr
ehen
sive
ques
tionn
aire
. The
que
stio
nnai
re
help
ed to
cat
egor
ize
adol
esce
nts i
nto
mor
ning
type
s an
d ev
enin
g ty
pes.
16 c
hild
ren
(10-
14 ye
ars)
wer
e ra
ndom
ly a
ssig
ned
to
a co
ntro
l gro
up (
1 1 h
ours
in b
ed) o
r an
expe
rimen
tal
grou
p (s
leep
dep
rived
with
max
imum
5 h
ours
in b
ed) o
n a
sing
le n
ight
in a
sle
ep la
bora
tory
. Sle
ep w
as
mon
itore
d us
ing
a po
lyso
mno
grap
h te
st, s
leep
late
ncy
was
mea
sure
d (ti
me
to fa
ll as
leep
), an
d te
stin
g w
as
done
the
next
day
. Tes
ts in
clud
ed th
e D
igit
Sym
bol
Sub
stitu
tion T
est,
Ste
er C
lear
test
for v
isua
l vig
ilanc
e,
WR
AM
L (a
sses
smen
t of l
earn
ing
and
mem
ory)
, To
rran
ce T
est o
f Cre
ativ
e Thi
nkin
g, C
hild
ren'
s C
ateg
ory
Test
(lea
rnin
g an
d pr
oble
m so
lvin
g),
Wis
cons
in C
ard
Sor
ting
Test
, and
Cal
iforn
ia V
erba
l Le
arni
ng T
est.
The
slee
p of
77
child
ren
in 4
th th
roug
h 6t
h gr
ades
(9-1
2 ye
ars)
was
mon
itore
d ni
ghtly
. Neu
robe
havi
oral
func
tion
test
s w
ere
mea
sure
d on
the
2nd
day
of th
eir
norm
al
slee
p sc
hedu
le. O
n th
e 3r
d th
roug
h 5t
h ni
ghts
, 40
child
ren
wer
e as
ked
to e
xten
d th
eir s
leep
by
1 ho
ur a
nd
37 c
hild
ren
wer
e as
ked
to r
estri
ct th
eir s
leep
by
1 ho
ur.
Test
s w
ere
repe
ated
on
the
6th
day.
Tes
ts in
clud
ed
finge
r tap
ping
(mot
or s
peed
), re
actio
n tim
e, c
ontin
uous
pe
rform
ance
test
(vis
ual a
ttent
ion
and
mot
or s
peed
), sy
mbo
l-dig
it sub
stitu
tion
(vis
ual m
emor
y, s
cann
ing,
and
sp
eed)
, vis
ual d
igit
span
test
(wor
king
mem
ory,
at
tent
ion)
, ser
ial d
igit
lear
ning
(wor
king
mem
ory,
le
arni
ng st
rate
gies
). S
urve
y of
478
1 1 l
th-g
rade
stu
dent
s fro
m 1
0 ra
ndom
ly
sele
cted
scho
ols.
Exc
essi
ve d
aily
sle
epin
ess
base
d on
"E
pwor
th S
leep
ines
s S
cale
." A
chie
vem
ent w
as b
ased
on
the
quar
tile
stud
ents
' ran
ked
in th
eir f
inal
exa
ms
of
thei
r firs
t sem
este
r. Th
ere
was
an
80%
resp
onse
rate
.
Stu
dy c
onfir
med
an
incr
easi
ng te
nden
cy w
ith a
ge to
be
less
sle
epy
durin
g ev
enin
gs a
nd m
ore
slee
py d
urin
g m
orni
ngs (
even
ing t
ype)
. Eve
ning
type
s de
mon
stra
ted
mor
e sl
eepi
ness
dur
ing
day,
rep
orte
d po
orer
sch
ool
achi
evem
ent,
less
atte
ntiv
enes
s, a
nd h
ighe
r co
nsum
ptio
n of c
affe
ine
beve
rage
s.
Cog
nitiv
e te
sts
with
sig
nific
ant d
iffer
ence
s bet
wee
n th
e co
ntro
l and
sle
ep-d
epriv
ed gr
oups
wer
e al
way
s w
orse
fo
r the
sle
ep d
epriv
ed, b
ut li
mite
d to
the
follo
win
g co
gniti
ve fu
nctio
ns: v
erba
l cre
ativ
ity a
nd th
e W
isco
nsin
C
ard
Sor
ting
Test
. All
othe
r tes
ted
area
s w
ere
sim
ilar
betw
een
cont
rol a
nd s
leep
-res
trict
ed gr
oups
.
Chi
ldre
n w
ho e
xten
ded t
heir
slee
p si
gnifi
cant
ly im
prov
ed
thei
r per
form
ance
on th
e di
git f
orw
ard
mem
ory
test
and
re
actio
n tim
e w
ith th
e co
ntin
uous
per
form
ance
test
. Th
ose
child
ren
who
dec
reas
ed or
mai
ntai
ned t
he s
ame
num
ber o
f sle
ep h
ours
as
they
had
at b
asel
ine
show
ed
no c
hang
e in
neu
robe
havi
oral
func
tioni
ng. T
he a
utho
rs
conc
lude
that
eve
n m
odes
t ext
ensi
ons i
n sl
eep
per
nigh
t cou
ld h
ave
bene
fits
in n
euro
beha
vior
al
func
tioni
ng.
Mea
n to
tal s
leep
tim
e w
as 6
.4 h
ours
/day
. Tot
al s
leep
tim
e di
d no
t sig
nific
antly
corr
elat
e w
ith e
xces
sive
dai
ly
slee
pine
ss. P
reva
lenc
e of
exc
essi
ve d
aily
sle
epin
ess
incr
ease
d sig
nific
antly
with
a d
eclin
e in
sch
ool
perfo
rman
ce.
on self-report. Self-reported shortened sleep time, erratic sleep/wake schedules, late bed and rise times, and poor sleep quality are negatively associated with academic performance for adolescents from middle school through college years. Future research designs must go beyond sub- jective feelings of sleepiness to measure academic perfor- mance. We need methodologies that include control groups and randomization.
Despite the drawbacks in the literature on sleep depri- vation among teenage populations, the preponderance of literature that recognizes the detrimental effects of sleep disorders is astounding and perhaps not fully appreciated among many primary care providers, school health profes- sionals, and educators. Professionals faced with school- aged children with learning or attention disorders have enough scientific justification to suspect that poor sleep may be a contributing factor. These children and their families should be asked about regularity and duration of sleep, bedtime resistance, sleep onset delay, night- wakings, sleep-disordered breathing, and increased day- time sleepiness.
References 1. National Heart, Lung, and Blood Institute. Slnr Sleeper. Available
at: http://www.nhlbi.nih.gov/health/public/sleep/starslp/parents/whysleep. htm. Accessed March 8,2004.
2. Blunden S, Lushington K. Kennedy D. Cognitive and behavioral performance in children with sleep-related obstructive breathing disorders. Sleep Med Rev. 2001;5(6):447-461.
3 . Fallone G, Owens JA, Deane J. Sleepiness in children and adoles- cents: clinical applications. Sleep Med Rev. 2002;6(4):287-306.
4. Wolfson AR, Carskadon MA. Understanding adolescents' sleep patterns and school performance: a critical appraisal. Sleep Med Rev. 2003;7(6):491-506.
254 Journal of School Health September 2005, Vol. 75, No.7