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To determine whether high school start time is associated with headache frequency in adolescents with migraine. Adolescence is marked by a physiologic delayed circadian phase, characterized by later bedtimes and wake times. The American Academy of Pediatrics (AAP) recommends that high schools start no earlier than 8:30a.m., but most high schools in the United States start earlier. The study hypothesis was that adolescents with migraine whose high schools start at 8:30a.m. or later (late group) would have lower headache frequency than those whose schools start earlier than 8:30a.m. (early group). This was a cross-sectional Internet survey study of US high schoolers with migraine recruited online through social media. Comparisons were made between the late group and the early group. The primary outcome measure was self-reported headache days/month. In total, 1012 respondents constituted the analytic set: n=503 in the late group versus n=509 in the early group. Mean (SD) self-reported headache days/month was 4.8 (4.6) versus 7.7 (6.1) in the late and early groups, respectively (p<0.001); mean difference -2.9 (95% CI -2.2 to -3.6). Mean (SD) self-reported hours of sleep on a school night was 7.9 (0.9) versus 6.9 (1.3), p<0.001. Adjusting for total hours of sleep, sex, taking a migraine preventive, days of acute medication use, hours of homework, grade level, and missing breakfast, mean (SD) self-reported headache days/month remained lower in the late group than in the early group: 5.8 (95% CI 5.3-6.2) versus 7.1 (95% CI 6.7-7.4), (p<0.001); mean difference -1.3 (95% CI -1.9 to -0.7). Adolescents with migraine who attend high schools that follow AAP recommendations for start times have lower self-reported headache frequency than those whose high schools start before 8:30a.m. If prospective studies confirm this finding, shifting to a later high school start time may be an effective strategy formigraine prevention in adolescents.

To investigate whether later high school start time is associated with lower migraine frequency in high school students with migraine. Adequate sleep is thought to be important in managing adolescent migraine. The American Academy of Sleep Medicine recommends teenagers sleep≥8hours/night. Adolescents have a physiologically delayed sleep phase, going to bed, and waking later than children and adults. The American Academy of Pediatrics (AAP) accordingly recommends high schools start no earlier than 8:30 AM. Cross-sectional observational study of U.S. high schoolers with migraine. Participants were recruited nationally using social media. Respondents attending high schools starting at 8:30 AM or later were compared to those attending earlier start time schools. The primary outcome was headache days/month. Two hundred and fifty-six subjects constituted the analysis set: 115 later group vs 141 earlier group. Age and sex did not differ. Mean (SD) self-reported headache days/month were 7 (5) vs 8 (7), respectively, (P=.985); mean difference (95% CI for the difference) was -0.8 (-2.3-0.7) days. Median (IQR) self-reported total hours of sleep/school night were: 5.6 (5.0-6.6) vs 5.6 (4.5-6.4), P=.058. Students attending later start time schools woke later (median [IQR] 6:38 AM [55minutes] vs 6:09 AM [59minutes], P<.0001) and left home later (median [IQR] 7:28 AM [28minutes] vs 7:02 AM [60minutes], P<.0001). Average commute time was also longer: 41 (21) minutes vs 28 (16), P<.0001. The vast majority in both groups reported missing breakfast at least once/week: 103/114 (90.4%) vs 128/141 (90.8%), P=.907. Hours of sleep did not correlate with headache days per month. High school start time does not have a large effect on headache frequency in high schoolers with migraine. Given the high variance in headache days/month observed in this study, a larger study would be needed to determine whether there might still be a small effect of starting high school at/after 8:30 AM. More research is needed to establish evidence-based recommendations about lifestyle factors in adolescent migraine management.

Sleep Data Lead Large School System to Push Back High School Start Times

We contribute to the school start time literature by using statewide student-level data from North Carolina to estimate start time effects for all students and for traditionally disadvantaged students. Descriptively, we found that urban high schools were likely to start very early or late. Later start times were associated with positive student engagement outcomes (reduced suspensions, higher course grades), especially for disadvantaged students. Achievement results were mixed, with positive and negative associations between start times and high school students’ test scores. Continued research is necessary to evaluate the efficacy of later start times as a scalable and cost-effective approach for boosting engagement and achievement.

A recent study by the University of Minnesota looked at eight high schools across the U.S. that chose later start times, from 8:00 a.m. to 8:55 a.m. The study found significant decreases in absences and tardiness as well as greater academic benefits for schools with the latest start times. Among the 9,395 students in the study, those who slept eight or more hours each night were less likely to report symptoms of depression and fall asleep in class. Moreover, after the change to a later start time, the number of car crashes in the districts studied decreased by 13%. Included are recommendations for schools and districts considering changing their high school start times.

High school start times and death on the road.

Although it is recommended that middle and high schools start at/after 8:30 a.m., most districts in the United States have not delayed start times. In Fall 2017, the Cherry Creek School District delayed school start times (Middle School [MS]: 8:00 to 8:50 a.m.; High School [HS]: 7:10 to 8:20 a.m.). This study examined changes to student sleep, extracurricular activities, homework, and academic engagement. Students in grades 6-11 completed online surveys during school hours in Spring 2017 (pre-change n=15,700) and Spring 2018 (post-change n=18,607). Questions included weekday and weekend bedtime [BT], wake time [WT], and total sleep time [TST], extracurricular activity participation, sleepiness during homework, and academic engagement. Parents (n=5,441) provided consent for a sample of students whose surveys were allowed to be linked year-to-year, as well as with demographic information. On weekdays, MS students reported slightly later BT (8m), later WT (39m), and longer TST (31m); HS students reported slightly later BT (13m), significantly later WT (61m), and longer TST (48m). When controlling for free/reduced lunch (FRL) status and race, results were similar for HS students; however, sleep duration increased more for MS students who received FRL (19m vs. 10m, p=0.05). Post-change, weekend oversleep was reduced by 38m for MS and 59m for HS students, and significantly more students obtained sufficient sleep (MS [≥9h]: 38% vs. 44%; HS [≥8h]: 27% vs 58%). Overall MS participation in sports decreased by 8%, while participation in HS sports, MS/HS activities, or HS employment decreased by <3%. Fewer students reported feeling too sleepy to do their homework for both MS (46% vs. 35%) and HS (71% vs. 56%). Scores on a measure of academic engagement were significantly higher after the start time change for both MS and HS students (p<0.001). This large study with linked data demonstrates that MS and HS students benefit from later start times with increased sleep duration, less sleepiness while doing homework, minimal changes to extracurricular participation, and improved academic engagement. Robert Wood Johnson Foundation

Negative health consequences of illicit drug use, such as cardiovascular complications and infectious diseases, increase the likelihood of the need for health care. However, evidence suggests that, with the exception of emergency services, drug users generally are medically underserved. Furthermore, the effect of illicit drug use on health care utilization is becoming an especially important issue for the criminal justice system, because an increasing proportion of inmates in correctional institutions have a history of drug use. This 1998–1999 study of 661 incarcerated men in the Kentucky prison system focused on predictors of unmet physical, behavioral, and overall health care needs among chronic substance users. Analyses revealed that White incarcerated drug users were more likely to report unmet physical and overall health care needs than non-Whites and those with high school education or above were more likely to report unmet physical, behavioral, and overall health care needs. In addition, more episodes of serious illness, more mental health problems, and poorer self-rated health were predictive of all three types of unmet health care needs. A longer career of drug use emerged as a significant predictor of unmet behavioral health care needs, whereas more frequent drug use in the year before incarceration predicted unmet physical health care needs. Further research directions and implications for in-prison health care planning are discussed.

Later school start times are associated with a number of benefits for adolescents. The purpose of the current review is to summarize the literature regarding the effects of delaying school start times on adolescent psychological health. We identified eight observational studies that examined the relationship between schools' starting times and psychological outcomes. Of these, three were longitudinal studies that reported measures of adolescent mental health improved following a start time delay. Two cross-sectional studies showed that mental health scores were higher in schools with later compared to earlier start times. Three studies found no relationship between start time and mental health. In the majority of studies reviewed, later school start times were associated with greater adolescent psychological health. However, inherent design drawbacks in the studies prevent us from concluding that these associations are causal. There are a wide range of potential benefits, beyond mental health, that later high school start times offer. This encouraging, emergent literature on delayed start times has led many school districts to consider changes to their start times.

Since later school start times are associated with increased sleep duration, our objectives were to identify mean school start times, the proportion of schools that start at 08:30 am or later, and determine if rurality was associated with school start times. We conducted web searches for start times of 1759 standard schools in British Columbia (BC), Canada. Schools were categorized as elementary, elementary-middle, middle, middle-high, or high school and linked to an Index of Remoteness. We calculated descriptive statistics and used Analysis of Variance to assess for start time differences by grade category. We used Spearman's rank-order correlation to assess if there was a relationship between start time and rurality. We found start times for 1553 (88.2%) of the included schools. The mean start time was 08:40 am (SD = 0:15) and ranged from 07:10 am to 09:45 am. There was a significant effect of grade category on start time, F (5, 1600) = 6.03, p < .001, η 2 =.02, 95% CI [.006, .031] such that elementary-middle schools started significantly earlier (M = 08:34 am, SD = 0:17) than other grade categories. Overall, 1388 (86.4%) schools started at 08:30 am or later. Rurality was significantly correlated with school start time (r = -.198), such that more rural schools started earlier. For the most part, school start times in BC meet recommendations that support childhood and adolescent sleep. Future research is needed to understand factors that promote the successful implementation of delayed school start times.

Do Canada and the United States Differ in Prevalence of Depression and Utilization of Services?

California Passes Nation’s First Law on School Start Times

To assess the effects of delayed high-school start times on sleep and motor vehicle crashes. The sleep habits and motor vehicle crash rates of adolescents from a single, large, county-wide, school district were assessed by questionnaire before and after a 1-hour delay in school start times. Average hours of nightly sleep increased and catch-up sleep on weekends decreased. Average crash rates for teen drivers in the study county in the 2 years after the change in school start time dropped 16.5%, compared with the 2 years prior to the change, whereas teen crash rates for the rest of the state increased 7.8% over the same time period. Later school start times may both increase the sleep of adolescents and decrease their risk of motor vehicle crashes.

The current study was designed to examine if improvements in high school graduation and attendance rates persist 4 years after start times later than 8:30 am. Socioeconomic status and race were accounted for in the graduation analysis. School-wide attendance and graduation records (n = 28 schools) from 1999-2017 were analyzed in August of 2021 using a repeated-measures analysis of variance at 5 points in time, 1 year predelay and 4 consecutive years postdelay start times. Graduation rates for students in grade 12 (n > 47,000) after postdelay year 4 increased from 80% to 90% (P < .001) and attendance rates in grades 9-12 (n > 80,000) improved from 90% to 93% (P = .012). Attendance and graduation rates for all students improved after 4 years following a delayed start. Economically disadvantaged students and Black students showed significant changes in graduation rates postdelay year 4 and White students significantly improved postdelay years 2, 3, and 4. Adolescent students, especially economically and racially disadvantaged students, have a vulnerability for obtaining adequate sleep. Delaying high school start times is a cost-effective intervention that could promote sufficient sleep and boost graduation and attendance rates. McKeever PM, Dodd R, O'Sullivan DM. Delayed high school start times and graduation and attendance rates over 4 years: the impact of race and socioeconomics. J Clin Sleep Med. 2022;18(11):2537-2543.

Sufficient sleep duration is associated with student health and wellbeing, but early secondary school start times limit students' sleep opportunity. Despite recommendations that all middle and high schools adopt a healthy school start time policy, one barrier to policy implementation is concerns about the impact on student participation in activities and employment. This study examined student extracurricular activity participation and employment before and after the implementation of healthy secondary school start times. Approximately 24,000 students/year (grades 3–11) completed three annual surveys (pre-change, post-change, follow-up) measuring sleep-wake patterns, extracurricular activity participation, and employment. Following the implementation of an earlier school start time, before-school activity participation decreased for elementary school students, but after-school participation was similar across years. Following the implementation of later school start times, there was a small decrease in after-school activity participation for middle and high school students (~3–4%). Equally important, middle and high school students reported significantly increased sleep duration with later start times, regardless of participation in before- or after-school activities and employment. Study findings support the recommendation for healthy school start time policies.