In Practice: Reflections from NPs and PAs

Scott Cuyjet, RN, MSN, FNP-C, practices adolescent medicine in the San Francisco Bay area.

As high school students wind down their summers, I am reminded of a study I read last year from the Centers for Disease Control (CDC), which concluded that most students at middle and high schools start their school day too early. Their early start times were disrupting their natural sleep pattern and subsequently leading to negative outcomes. Other U.S. data, from the 2007 Youth Risk Behavior Survey, indicate that less than one third of students got at least 8 hours of sleep on an average school night.

As a parent of teenagers, I am reminded of that statistic every night as I try to get them to sleep at a reasonable hour, and every morning, as much as I struggle to get up, it is much worse for my 15- and 16-year-olds. Every day I have to cajole and sometimes force them to get up and get ready. They slowly move through their morning routine like zombies as I remind them of things they need to do to get ready.

These research findings are also relevant to my job as a nurse practitioner, as most of my patients are high-school-age. This is one of the reasons our clinic opted to open at 9:30 a.m. at its inception 25 years ago. At that time, our founders were aware of the data supporting the importance of sleep for adolescents. Some of the documented health deficits associated with lack of sleep include being overweight, alcohol and substance use, smoking, and poor academic performance.

Today, there are many barriers to adolescents getting enough sleep. One of them is the use of electronic devices like cell phones, tablets, eReaders, and laptops, which are often used right before going to sleep. In a 2014 paper, sleep researchers documented disrupted Circadian rhythms in people using light-emitting e-readers before bedtime and noted the particular challenges for children and adolescents, “who already experience significant sleep loss.” The authors called for further epidemiological research evaluating the long-term health and safety consequences of e-readers. (My mom, a librarian, would argue that this is a reason to go back to paper books, at least before bed.)

Another source of sleep deprivation, according to my adolescent patients, is the amount of homework they have on top of other activities. In one recent article, students report spending a nightly average of over three hours on homework. Many students don’t even get to start homework until later in the evening given their after-school activities. A recommendation by one national homework expert cited in that article is: “multiplying the student’s grade level by 10 to get the optimal amount of time that should be spent on homework each night; this means that freshmen in high school should spend no more than 90 minutes and seniors no more than 120 minutes on homework each school night.” Granted, this recommendation can only be implemented with buy-in and participation from teachers.

In response to this issue, the American Academy of Pediatrics recommends that middle and high schools should start at 8:30 a.m. or later to allow students the opportunity to get the recommended amount of sleep on school nights (about 8.5–9.5 hours). In my own experience, I would say that 9:00 or 9:30 a.m. would be even better start times, although I recognize that getting kids to school at that time might be difficult for parents whose work day starts before then.