Why, how, and what you can do as an advocate in your community.

Sleep advocacy is a relatively new concept in sleep medicine, but increasingly, sleep professionals from a variety of backgrounds are seeking opportunities to provide education about the critical importance of sleep to good physical and mental health, and to promote the concept of sleep health to patients as well as to the public and local and national policymakers. While organizations such as the American Academy of Sleep Medicine (AASM) and the National Sleep Foundation provide a wealth of good consumer information and have developed national initiatives to promote healthy sleep behaviors, many sleep professionals now recognize there may be opportunities to become involved in these efforts in their own communities.

Perhaps chief among the opportunities to provide a real service to the community as a “sleep expert” is the issue of healthy school start times (ie, bell times for middle and high schools at 8:30 am of later). This article reviews the importance of school start times as a public health issue together with general principles of community engagement and education. It also outlines specific strategies for sleep professionals to become advocates in their own communities.

Educating and Engaging Community Stakeholders

Over the past two decades, hundreds of middle and high schools in urban, suburban, and rural communities have successfully delayed starting times to better accommodate the unique sleep needs of adolescents.

A substantial body of evidence consistently links the very early bell times that have been common in US middle and high schools since the mid-20th century to a host of physical, psychological, and school performance problems in teenagers. Multiple studies have now demonstrated that delaying school start times can bring substantial and myriad benefits to adolescents, including increased and more appropriately timed sleep as well as improved school-related outcomes such as decreased rates of absenteeism, tardiness, drop-outs, and disciplinary referrals. Even more compelling is the evidence associating later school start times with reduced rates of depression and suicidal ideation, substance use, and car crashes, especially given that accidental injuries (including car crashes) and suicide are the 1st and 3rd leading causes of death, respectively, in US adolescents. This evidence has led the American Academy of Pediatrics, the American Medical Association, and the AASM, with recent support from the National Parent Teacher Association, to recommend that middle and high school classes begin no earlier than 8:30 am.1-4

Despite this compelling evidence, over 85% of US middle and high schools require attendance before 8:30 am, with many schools starting in the 7 am hour or even earlier.5,6 Many communities have found that efforts to change bell times create significant political challenges, however strong the evidence justifying change. Frequent (and understandable but by no means insurmountable) stakeholder concerns include potential costs to taxpayers related to increased busing costs, as well as speculation about how new school schedules might impact traffic, commuting time, afterschool jobs for both teachers and students, daycare arrangements, parent work schedules, and sports and other extracurricular activities. Coupled with widespread lack of knowledge about basic biological facts regarding adolescent sleep—and the common misperception that sleep is a luxury at best, a sign of weakness at worst—stakeholders commonly push back with fears and speculations about perceived inconveniences and costs.

Despite these political challenges, hundreds of communities have found feasible, affordable ways to implement and maintain healthy school start times. Their experiences show that the perceived obstacles almost always turn out to be unfounded or surmountable.7 While every community’s story is shaped by local conditions and values, almost every successful change shares certain characteristics, including:

  • Strong commitment by school leaders to promote the benefits of appropriate sleep for student health, safety, and academic and athletic performance.
  • Targeted community education about adolescent sleep and the research justifying changes.
  • Instruction in prioritizing sleep, time management, and sleep hygiene so students and families can use the later hours effectively.

In other words, successful change requires that communities understand the rationale for later start times for middle and high school students and prioritize sleep as a health imperative for students—analogous to principles of good nutrition and adequate physical activity that are actively promoted through school policies (eg, healthy school lunches, mandatory physical education, and health education). Here the expertise and authority of sleep professionals can be invaluable in raising awareness both among school leaders and the community at large. Once these stakeholders understand and prioritize sleep, they can work together to find creative solutions to the logistics of change, and many seemingly daunting issues become trivial, or disappear entirely.7

Ultimately, implementing healthy bell times requires a climate in which community stakeholders actively want and push for school hours that allow for healthy sleep. Building such “political will” requires a multipronged, multidisciplinary approach that includes diverse players ranging from sleep researchers and clinicians, pediatricians, school superintendents, social workers, student advocates, and legislators.

Judith Owens, MD, MPH

Judith Owens, MD, MPH

This April, the first National Conference on Adolescent Sleep, Health, and School Start Times, held in Washington, DC, convened sleep scientists, school leaders, teachers, counselors, policymakers, health professionals, and economists who presented the science and discussed why sleep and school hours matter and how school districts can ensure sleep-friendly bell times. Experts on teen sleep and school bell time change collaborated with community leaders and grassroots advocates to demonstrate the power of interdisciplinary relationships in translating science into policy. In particular, stories shared by superintendents and school board members reinforced the need for help from sleep professionals to create communities that value sleep. They emphasized the enormous power that researchers and clinicians have to shape policy when they work with school and community leaders and themselves become advocates for sleep health.

This power is also playing out in state houses across the country. To date, school-start-time legislation has been introduced into 11 states—including 3 bills passed since 2014.8 Currently, California is poised to pass a landmark bill prohibiting middle and high schools from requiring attendance before 8:30 am, which would make California the first state to translate adolescent sleep research into policy. Sleep professionals, researchers, and state sleep societies have played a key role in many of these legislative efforts, providing oral and written testimony and vetting sleep education materials for legislators and voters.

Getting Involved in Your Community

While the needs of individual communities vary, as does the specific expertise of sleep professionals, the following suggestions can serve as a guide to establishing meaningful engagement at the community level.

Terra Ziporyn Snider, PhD

Terra Ziporyn Snider, PhD

  1. Educate yourself on the biology of teen sleep, the impact on health of chronic sleep loss, and the evidence supporting school start time change (SSTC).
  2. Become informed about where your school district stands regarding this issue, and the involvement of the major decision-makers (superintendents, school boards, principals, etc) and stakeholders (parents, students, teachers, community recreation and after-school program directors, etc). Very often, community grassroots organizations formed by parents and other advocates have already begun to broach the issue and are the “boots-on-the-ground” volunteers and organizers working to change start times.
  3. Meet with community leaders (for example, school superintendents, principals, PTAs, teachers unions). Keep in mind that some stakeholder groups, such as parents of student athletes and elementary school parents, may oppose SSTC with various concerns (eg, about sports practice times or moving elementary school start times earlier) and can be very strong negative voices with power to obstruct change even if the concerns are unfounded or resolvable.
  4. Serve as a “sleep resource” to community organizers, including assisting them in interpreting the literature. For example, you might give community presentations to translate sleep science into lay language. You might help explain strengths and limitations of studies put forward by groups trying to “debunk” the evidence supporting changing school start times.
  5. Help reframe the discussion as primarily about health and safety rather than just academic performance.
  6. Develop a list of “sleep myths and misconceptions” that are frequently cited by opponents to derail SSTC efforts, and “debunk” them in your presentations and conversations with stakeholders. These myths include “Teens would go to sleep earlier if their parents just made them do it,” “If school starts later, kids will just stay up later,” “Teens can make up sleep on the weekends,” and “Kids need to learn to wake up early—that’s real life.”
  7. Assist school districts in developing a plan to assess outcomes of SSTC. Assessments can range from a formal research project utilizing pre-post survey and administrative data (attendance rates, standardized test scores, etc) to informal interviews with key stakeholders.
  8. Engage your local professional organizations in going on record to support SSTC.


There is no question that sleep professionals have a critical role to play in educating the public and highlighting the importance of sleep to health and well-being, the benefits of which to society are potentially enormous. The opportunity for all sleep professionals to become involved on many different levels in the school start time change effort in our own communities is timely, impactful, and likely to have a long-lasting positive impact, not only on the health and safety of our youth, but on the credibility and public perception of our field.

Judith Owens, MD, MPH, is the director of sleep medicine at Boston Children’s Hospital and professor of Neurology at Harvard Medical School. She was the lead author of the 2014 American Academy of Pediatrics Policy Statement on School Start Times and on the board of Start School Later. Terra Ziporyn Snider, PhD, is the executive director and co-founder of Start School Later. A former associate editor at JAMA, she is a medical writer and historian whose works include The Harvard Guide to Women’s Health.


1. Adolescent Sleep Working Group Committee on Adolescence and Council on School Health. School start times for adolescents. Pediatrics. 2014;134(3):642-649.
2. American Medical Association. Insufficient Sleep in Adolescents 2016; https://policysearch.ama-assn.org/policyfinder/detail/school%20start%20time?uri=%2FAMADoc%2FHOD.xml-0-5024.xml, H-60,930.
3. Watson NF MJ, Wise MS, Carden KA, Kirsch DB, Kristo DA, Malhotra RK, Olson EJ, Ramar K, Rosen IM, Rowley JA, Weaver TE, RD. C. Delaying middle school and high school start times promotes student health and performance: An American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2017;13(4):623-625.
4. National Parent Teacher Association. Resolution on Healthy Sleep for Adolescents. 2017; http://www.pta.org/advocacy/content.cfm?ItemNumber=4782&navItemNumber=5192. Accessed July 22, 2017.
5. Wheaton A, Ferro G, Croft JB. School start times for middle school and high school students- United States, 2011-12 school year. August 7, 2015.
6. National Center for Education Statistics Schools and Staffing Survey (SASS). Public School Data File. Washington DC: U.S. Department of Education; 2011-12.
7. Owens J, Drobnich D, Baylor A, Lewin D. School Start Time Change: An In-Depth Examination of School Districts in the United States. Mind, Brain, and Education. 2014;8(4):182-213.
8. Start School Later. Current Legislation. 2017; http://www.startschoollater.net/legislation.html. Accessed July 16, 2017.