Average sleep on school nights for boys and girls in 2012-2013

Less Than 10% of High School Students Get Enough Sleep At Night

A recent study was published by the Centers for Disease Control on the amount of time that teenagers get on an average school night. Students were surveyed over school years from 2007–2013. The results of the survey were alarming, even to those of us who spend a lot of time worrying about the sleep of teenagers. The results varied from year to to year but very few students were getting ≧ 9 hours of sleep per night (6.2–7.7% of females and 8.4% of males). The Center for Disease Control recommends that teenagers get 9–10 hours of sleep per night. Here are charts showing these percentages by gender. Only the kids in blue are getting enough sleep:

Average sleep on school nights for boys and girls in 2012-2013

Average sleep on school nights for boys and girls in 2012-2013

Additionally, the amount of sleep that teenagers get as they progress through high school decreases over time, likely due to a combination of circadian preference and increasing homework load. About 5% of high school seniors are getting an adequate amount of sleep:

% of Teens Getting Adequate Sleep by Gender and Grade Level

% of Teens Getting Adequate Sleep by Gender and Grade Level

Race had some effects as well, with the percentage of black boys and girls getting ≦5 hours of sleep per night being more common than their white peers. Because of the nature of this study, we do not know why this is.

These data are even worse than I would have anticipated. It shows that sleep deprivation is endemic in teenagers. Moreover, it seems like structural change is necessary to address this issue. The two obvious targets are school start time times and homework workloads. Apologists for the status quo point to the difficulty and expense related to change; however, I ask you: can we afford to wait?

Later School Start Times Can Save Lives

The documentary Sleepless in America on the National Geographic Channel starts with the powerful story of a man who lost his wife and two of his children after they were struck by a driver who had fallen asleep at the wheel.

Drowsy driving is equivalent to drunk driving in terms of impairment and risk of accident. However, no one thinks drunk driving is a good idea, but school schedules and heavy homework loads are structured to ensure that many teens are driving drowsy all of the time. Car accidents are the most common cause of death in teenagers.Yet another study has shown that later school start times reduce the risk of car accidents in teens.

A group of researchers led by Dr. Robert Varona published an important paper in the Journal of Clinical Sleep Medicine. They studied two adjacent counties in Virginia, Chesterfield and Henrico. The counties were similar in the make up of people living in them based on census data and the make up of teenagers attending the school. The main difference between the two communities was school start times: Chesterfield County (CC) schools start at 7:20 A.M., and Henrico County (HC) schools start at 8:45 A.M.. The students with the later school start times (HC) had a crash rate of 37.9/1,000 drivers/year. (This means that out of 1,000 drivers age 16–18 years old, 37.9 will have an accident). The students with earlier school start times (CC) had a rate of 48.8/1,000 drivers/year, which is a 28.7% increase in the risk of car accidents. Accidents were most likely to occur on the commute to and from school:

Weekday crash rate of 16 to 18-year age groups in Chesterfield County and Henrico County for School Year 2010– 2011

Weekday crash rate of 16 to 18-year age groups in Chesterfield County and Henrico County for School Year 2010– 2011

When I see teenagers in Sleep Clinic, for any reason, I discuss the risks of drowsy driving at length with them. Specifically:

  • Sleepy drivers are not good judges of how impaired they are.
  • Even small amounts of alcohol greatly increase the risk of car crashes in drowsy drivers.
  • Rolling down the window, turning up the radio, or (God forbid) talking on the phone DO NOT help keep you awake.
  • The only two interventions which may reduce the risk of a crash are
    • Avoiding driving when drowsy altogether
    • Taking a brief nap
    • Drinking a caffeinated beverage

Imagine if the school was giving kids a drink of alcohol every day before sending them out on the road. There would be a massive outcry. This is essentially what many school districts are doing with inhumanely early school start times. if the purpose of school are to educate our teenagers and keep them safe, why do we persistent with schedules that increase the risk of injury and death?

Further information is available here:

Even if you do not have teenagers who drive in your household, there are sleep deprived teens in your community and this affects your safety as well. Are you a teenager? A parent? An educator? Any thoughts you have on sleep and safety in teenagers are welcome below.

Get That Television Out of Your Kid’s Room. Now.

What would you say if I told you that there is one thing you can do to avoid sleep problems in your child as they get older, even into adulthood? It’s really easy. In fact, if you are lucky, you just have to avoid doing something. An added side benefit is that this intervention will help keep them from getting fat. Here it comes:

1. Don’t put a television in your child’s room.

2. If there is a TV in your child’s room, take it out. This is not a punishment. This is you taking care of your child’s health.

I see kids for a variety of sleep problems. Many of them have been present for years. Some, like obstructive sleep apnea or restless leg syndrome, are due biological reasons– these kids are going to have issues no matter what.  Others are purely due to bad habits. Many are a mixture of both.  There is a common thread in many of the problems characterized by dysfunctional sleep behaviors, there is one thing that I see over and over in children and teenagers with sleep problems: televisions, computers, and phones in their room, used during the time they should be sleeping. It is critical to avoid this if possible, or address if it is already a problem.

There is a lot of research documenting significant problems associated with television viewing in the bedroom.

This has become so much more complicated in the era of smartphones, online gaming, and social media. Several years ago, a paper was published entitled “Adolescents Living the 24/7 Lifestyle: Effects of Caffeine and Technology on Sleep Duration and Daytime Functioning”. The authors developed a metric they called “the multitasking index” which described the use of various electronic devices (cell phones, TVs, computers) after 9 PM). As teens used more of these devices after 9 PM, they were more likely to be sleepy and use more caffeine, thus perpetuating the vicious cycle of adolescent sleep.

As you can imagine, it is hard to wrest an iPhone or laptop from your teenager once they are heavily reliant on them during the late night hours. That’s why it is so much better to set clear ground rules when your child is younger. I would recommend these rules for any parent.

  • No TVs in the bedroom.
  • Computers, phones, game systems should out of the room after 9 PM. Maybe a bit later for teens. I have seen many teens use the phone as an alarm. Don’t do this. Get them an alarm clock. This avoids surreptitious social media use in the evenings (Facebook, Twitter, texting, etc.)

This may seem punitive to some kids if it breaks an established pattern. To me, falling asleep with the TV is another problematic sleep onset association. Just like little kids may wake up at night and need a parent present to help them fall asleep, older children and adults may need the television to fall and stay asleep. The problem is that the light and sound can disrupt sleep quality. The fact is, everyone can sleep without it.

Want to Stop Cosleeping? Here’s How

In last week’s post, I talk about reasons why you might want to avoid cosleeping, because of SIDS risk in infancy, and the fact that it can be associated with poor sleep as children get older. Now, I wanted to offer some advice on how to stop cosleeping. [Note: as in the previous post, I use “cosleeping” to mean “bedsharing”; although this is a bit imprecise, I do think that it reflects the common usage of the term.]

When is cosleeping OK?
After putting up my post I got some great feedback from around the web from readers, friends, and colleagues. People I know and respect have chosen to cosleep with their children and have been happy to do so. One great example is Dr. Claire McCarthy, who wrote about cosleeping with her children on the Huffington Post.
This made me reflect on what would make me OK with ongoing cosleeping if a family asked my opinion. My goal for families is good enough sleep, which in this case means:

  • Your child is older than a year and thus the risk of SIDS is minimal.
  • Everyone is sleeping well
    • Enough space in the family bed (Thanks to Olli Orajärvi from Finland for this one)
    • Parents are not being disturbed during the night.
    • Parents and children feel well rested in the morning and are not sleepy during the day.

If all of these circumstances are not met, then I think you should stop cosleeping.

How to stop cosleeping

There is no magic bullet for fixing sleep problems. How you address this issue depends on how and why you are cosleeping with your child. But no matter your circumstance, there are some important elements to a successful transition. For more on why people fail to fix sleep issues, please read my post on Sleep Training Mistakes and Pitfalls.

General Recommendations:

  • Be consistent: The number one reason I see families fail at extricating their child from their bed is that they are inconsistent. Either your child is sleeping in your bed or he or she is not. If you relent even once in a while during the process of establishing a new sleeping pattern, you will reinforce the behavior you are trying to extinguish. Remember that intermittent reinforcement is a powerful mechanism for encouraging undesirable behavior. (Again— if your kid comes into your bed once a while, and you do not regard this as a problem, you don’t need to proceed with any of this).
  • Have a plan: To be consistent, you have to know exactly what you are going to do. It is hard to come up with good plans on the fly in the middle of the night. Make sure that all caregivers are on board with the plan.
  • Have a “quit date”: I highly recommend that you mindfully chose a time for a change and do not, say, start a change the day before a vacation, or before your mother in law comes to visit
  • Make your child’s room special: Some children may be apprehensive about spending time alone in their room. Spending fun and special one on one time. Take him to pick out some new pajamas and sheets. Pick out a new stuffed animal to use as a transitional object.

Based on type of cosleeping

  • Reactive cosleeping: Your child comes into your bed at night but in theory they are supposed to sleep in their room.
    • Addressing sleep onset associations:(): This is the most important thing to do: How your child falls asleep is the key to successful sleep. Sleep onset association are when your child falls asleep under circumstances absent during the night: usually this involves you being present when he falls asleep. These sleep onset associations may be subtle. Do you turn out the lights and then have to go back in to settle your child? Does he come out of the room multiple times at bedtime until you lay down with him.
    • One of the most challenging forms of reactive cosleeping is due to  early morning awakenings. Although it is really tempting to just relent at 4 or 5 in the AM, if you want your child to stop this behavior, they will not do it on their own. In this scenario, I recommend the OK to wake clock. The correct way to use this is to set the “OK to wake” alarm to 10 minutes after their usual wake time, and then move it 10 minutes later a day.
    • Sleeping bag on floor: For children who come into your bedroom on his or her own, I highly recommend that you provide them an option for sleeping in your room without disturbing you. A sleeping bag and pillow on the floor is a great solution for a transition. Many children will stop using this of her own accord with time, especially once they realize that it is not as comfortable as her own bed.
    • Bringing you child back to her room every time: If your child does not want to sleep on your floor and insists on disturbing you every night, you need to walk him back to their own room. Every time. Most kids will not pitch a huge fit in the middle of the night. If they do, you can employ the door closing strategy. This means bringing your child back to bed with the expectation that he will stay in bed. If he gets up and leaves the bed you close the door for one minute and hold it shut. If you open the door and he is not in bed you close it for two minutes, and increase as needed. This is a nuclear option, but sometimes it needs to be employed.
  • Intentional cosleeping: Your child sleeps in your bed every night for the whole night, and this is a long-standing pattern. In this scenario, many families want to stop once they are expecting another child, or their child hits a milestone such as kindergarten. In this scenario, you need to go gradually. Why is this different? Often your child does not know another way to sleep.
    • Discuss with your child at an age appropriate level. Often this transition may happen at an older age. Be honest. Tell her that she is a big girl now and is almost ready to spend the night in her own bed. Tell her that Mommy and Daddy (or Mommy, or Daddy, or Daddy and Daddy, or Mommy and Mommy) need some time by themselves.
    • Start moving bedtime into your child’s room: If your child spends the whole night in your room, start doing all of bedtime in his room and then moving him into your bed for a few days, as a dress rehearsal for spending the night in his own bed.
    • Napping in her bed first:If your child is still napping, this may be a good time for your child to practice sleeping on her own.
    • Bedtime fading (moving bedtime later) can be a big help with this transition.
    • Consider camping out If (you or) your child is very apprehensive about this, consider a “camping out” approach where you temporarily move to an air mattress on the floor of your child’s room. I would recommend NOT bedsharing at this point to smooth the transition.

Other questions that may come up:

  • How long will this take? It is somewhat hard to predict. It may go really smoothly if your child is ready for this change and take a day or two. In other children, who may be more reluctant, you may need to go more slowly. I would expect this to take no more than two weeks. If you try to stop cosleeping and it is a disaster, I recommend discussing it with your pediatrician or a sleep specialist. However, remember the extinction burst: your child’s sleep will typically worsen before it improves, and such difficulties may occur 2–3 days in.
  • What if my child gets sick/has a nightmare, etc?I would encourage you to try to follow your plan as strictly as you are comfortable. A quick cuddle in the middle of the night in their room is OK; bringing him into your bed for the rest of the night may undo weeks of hard work. I would say that if you are not ready to be firm on this topic for a month, I would hold off for a bit. After your child is successfully sleeping in his bed for a month or so, I think that it may be OK to bring them into your bed if you really have to (e.g. if he is running a high fever) with the understanding that you may need to be a bit firm afterwards.
  • What if I’m not sure if I am doing the right thing? If you are ambivalent and telegraph that to your child, you are setting you both up for failure. Perhaps you should wait for a bit. However, if you have come up with a plan and started executing, I encourage you to follow through in spite of middle of the night misgivings. Give it a week. If you stop too soon, you and your child have suffered for nothing, and possibly made it more difficult for yourselves in the future. I think you can do it.

So this has turned into an epic post. Let me know if you have other thoughts on this topic, or questions I have not answered. Also, if you have successfully navigated this transition, please let me know what worked for you.

Do You Want Your Kid to Be a Good Sleeper? Don’t Cosleep

As a sleep doctor, and a parent, I have a problem with cosleeping. Cosleeping in infancy has been found to cause a small but significant increase in SIDS risk. We chose not to co-sleep with our sons. Since infancy, they have always slept better in their own beds, and so did we. [To be clear, when I say “cosleeping in this blog post, I mean bed-sharing and not room sharing]. It’s not just a safety issue, however. I think that kids and parents sleep better when they have their own space, and that learning to sleep well is an important life skill for children that is best learned at an early age.

Like many topics in parenting, cosleeping has become a political issue. I personally do not recommend it to friends or patients, because of the risk of death in infancy, and because it seems to lead to poor sleep for the whole family. (Here are some great illustrations of this). The likely mechanism is via inappropriate sleep associations. I also think it is unhealthy for parents’ lives to revolve around their children 24 hours a day, and that sometimes, children have to “fit within the frame”. That includes having children being able to be apart from their parents for the night. As I have stated previously, there is no evidence that sleep training harms children.  Moreover, I am unaware of any long-term studies which show direct benefit of cosleeping for children who are in otherwise loving homes. Parents who disagree with me may site Dr. William Sears’ work, but many of the researchers cited by him claim that their research was misrepresented.

A recent study in Norway supports my experience on this topic. The study found that children who routinely cosleep in infancy tend to be poor sleepers as toddlers. (Thanks to my friend Susan Curley at Joyeux Parenting for bringing this to my attention). This study surveyed over 55,000 mothers, taking into account factors such as breast- vs. bottle-feeding, sleeping practices, child sleep duration, and nocturnal awakenings. There were several important take-homes from this study:
1. Bedsharing at six months of age was associated with shorter sleep and more frequent awakenings at 18 months of age.
2. Poor sleepers at six months had were more likely to have problems at 18 months of age.
3. Breastfeeding at six months seemed to have a mild protective effect against awakenings at 18 months of age.
This is a strong study because it follows a large number of families from birth and sees what happens over time, as opposed to surveying parents who are having difficulty and asking them to remember what they were doing six months previously. (I don’t know about you, but I’m not sure what I was eating for lunch yesterday, let alone how my kids were sleeping a year ago).

There are two pathways to cosleeping which I have observed:

  • Intentional cosleeping: where parents have made it part of their agenda to bed share with their child
  • Reactive cosleeping: where parents get into the habit of having their child fall asleep in their bed at night, or bring them into bed in the middle of the night when they wake up.

Either way, this seems to result in poor quality sleep. I have found that both in the comments on this blog and in my clinic, habitual cosleeping seems to be associated with lousy sleep. Here’s a sample:

I really hope you can help us. We have a 15-month-old that from birth has been cosleeping. When we coslept, Emma would wake up 3–5 times to nurse since she didn’t know how to self soothe. About two weeks ago I weaned her completely off breastfeeding and after a week of weaning, she began sleeping through the night! Fast forward two weeks later. We are now transitioning her to her crib. It’s been about 5 days since we stopped cosleeping and we are still having problems with her waking up crying hysterically…It takes my husband or myself an hour or more to put her back to sleep. Katrina P

I really feel for this family. They are obviously having a hard time. This mother has been feeding this child three to five times per night for fifteen months. That adds up to a lot of poor sleep for both mother and child. I get grumpy if I get woken up even once at night, be it by a child or a page from the sleep lab.

Even outside of this, there is another significant issue with cosleeping: where does it end? It seems like children seldom give it up on their own. Do you try to transition your child out of bed when they stop nursing? When they start kindergarten? When they enter puberty? When they leave for college? Let me tell you the hard truth: it is much easier to fix a sleep problem at six months than six years of age. 

Perhaps I am way off of base here, and there are a huge number of children staying in their parents’ bed, where everyone is getting a terrific night of sleep. I certainly think that “if it ain’t broke, don’t fix it.” I’d love to hear your thoughts on this controversial topic.

But if you are not one of these happy cosleeping families, and have fallen into a cosleeping pattern you can’t break, have hope! Next week: a post on how to stop cosleeping and start sleeping well.

One Patient, One Year After a Double Lung Transplant

A little over a year ago, I had a guest post from a former patient of mine with end-stage cystic fibrosis lung disease. Renu Linberg wrote movingly:

I’m trying to get comfortable with being uncomfortable, with the stressful days, with the breathless, can’t-get-off-the-couch days. I am learning to sit through those moments, and acknowledge the anxiety, or fear, or stress. For once those emotions get acknowledged, they seem to have less of a hold on my mind, as though that’s all they wanted in the first place. However, as my body has slowed down, my ability to cope has changed. Where I was once able to go for a swim or a hike, I can now only walk very slowly with a lot of oxygen pumping into my nose

About one year ago, she received a double lung transplant. And now she has written about this for an online magazine called Hello Giggles. She describes waiting in the hospital immediately before her transplant:

I saw my hand, with the slightly curved nails, and the pale fingertips, signing my name, and I knew that it was a hand connected to my arm, connected to my body, yet the whole situation was too surreal to fully, in the moment, process.

With that signature, essentially, I was saying, “Permission to perform a double lung transplant, granted. Proceed forth with the utmost caution and delicacy, as I am rather fond of living, despite my own lungs inability to keep doing so.”

Fortunately, the surgery was a success, and things have gone well for Renu:

I am almost one year post transplant. I can now take the stairs again, and walk up hills. I have returned my supplemental oxygen and no longer have an IV pole as a dance partner. I can laugh and sing without wheezing and stopping to catch my breath. I am finally embracing my slightly different life, and realizing that while it may be an odd life, and wildly unpredictable, the best ones always are.

Honestly, this brought a smile to my face, and (I confess) a tear to my eye. Renu is a success story, and there are many others like her. However, not everyone is so lucky, because there is a shortage of organ donors.  According to Organdonor.gov, almost 120,000 people are waiting for organ transplantation, and eight die every day. One donor can save eight lives. If you aren’t already registered, please do so.

Daylight Savings Time And Your Child: Avoiding Problems When “Falling Back”

Ahh, autumn. Halloween costumes, fall foliage, carving Jack-O-Lanterns and enjoying the crisp bite of a fresh apple. Those of use who live in New England often cite this season as the finest of the year, prior to the long nights and cold days of winter. There is one part of it that I don’t look forward to as a parent of small children, and a sleep doctor: the end of Daylight Savings Time (DST) when the clock falls back by one hour. This year, clocks in the United States will fall back by one hour at 2 AM on Sunday, November 2nd. There is some evidence that DST is associated with adverse health and safety effects, but this is controversial; Ezra Klein nicely outlined this in the Washington Post.

If you don’t have children and don’t work nights (medical residents on call that night– I feel for you as you will be on call for another hour), congratulations! You get an extra hour of sleep. For those of us with little children who get up earlier, however, this can be painful. The reason is that little children tend to get up earlier than their parents would like them to. (Teenagers are a different story as they usually have problems with getting up late– thus they struggle with the beginning of DST, or “springing ahead.“) Thus, a child who is sleeping from 8 PM to 6 AM will now be on a 7 PM to 5 AM schedule. The sleep period has not moved, but the clock has.

Fortunately this is pretty easy to address. Move your child’s sleep period later by 30 minutes for three days before “falling back” and then back to their old schedule on the “new time”, effectively moving their sleep period an hour later. In this example, you will have your child go to sleep at 8:30 PM to 6:30 AM for three days before falling back, then move them back to the old schedule at the new time (8 PM to 6 AM).

Not everyone’s child will sleep in 30 minutes later but the important thing is to move bedtime. This approach will hopefully cushion the landing from “falling back” and help you get a little more shuteye.  I have found this to be useful in my household and my clinic, where the ramifications of DST seem to extend beyond a simple shift; many children seem to have disrupted sleep at night as well around this transitional period. In my experience, these difficulties may be exaggerated in children with autism, so it may be worth a more gradual transition in sleep periods. If early morning awakenings remain an issue, here are some more strategies for addressing them.

I’d love to hear about your experiences with this. Has this been a problem for you in the past?