School-based sleep education program improves sleep and academic performance of school-age children

Accepted Manuscript Title: School-based sleep education program improves sleep and academic performance of school-age children Author: Reut Gruber, Gail Somerville, Lana Bergmame, Laura Fontil, Soukaina Paquin PII: DOI: Reference:

S1389-9457(16)00048-4 http://dx.doi.org/doi: 10.1016/j.sleep.2016.01.012 SLEEP 3005

To appear in:

Sleep Medicine

Received date: Revised date: Accepted date:

11-10-2015 28-1-2016 28-1-2016

Please cite this article as: Reut Gruber, Gail Somerville, Lana Bergmame, Laura Fontil, Soukaina Paquin, School-based sleep education program improves sleep and academic performance of school-age children, Sleep Medicine (2016), http://dx.doi.org/doi: 10.1016/j.sleep.2016.01.012. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

School-Based Sleep Education Program Improves Sleep and Academic Performance of School-Age Children Reut Gruber., Ph.D.1, 2, Gail Somerville, M.A.3, Lana Bergmame, M.A.2, Laura Fontil, M. A.2 Soukaina Paquin, B.A.2,

1) Department of Psychiatry, McGill University. Montréal, Québec, Canada. 2) Attention, Behavior and Sleep Laboratory, Research Centre of the Douglas Mental Health University Institute, Montréal, Québec, Canada 3) Riverside School Board, Saint-Hubert, Québec, Canada

*This work was performed at the Douglas Mental Health University Institute and the Riverside School Board, Qubec Canada

Funding: Supported by a Canadian Institutes of Health Research grant (#187977, to Reut Gruber).

Conflict of interest: The authors have no conflict of interest to disclose.

Corresponding author: 6875 LaSalle Boulevard, Verdun, Montréal, Québec, H4H 1R3, Canada. Telephone: 514-761-6131 ext. 3476; Fax: 514-762-3858; Email: [email protected] Acknowledgments Supported by a Canadian Institutes of Health Research grant (#187977, to Reut Gruber). We would like to formally acknowledge the participation and contributions of the following Individuals from Riverside School Board Paul Enros Jennifer McNeil Dan Brouillette Enzo DiIoia Deborah Angelus Elizabeth Poitras Myra Kestle James Stadnyk Nathalie Guenefeld We would like to thank the students, parents and teachers that participated in the program and in the study Page 1 of 18

1 Highlights Created a sleep education program using participatory research approach Evaluated the program using objective sleep measures and report card grades Children's sleep and academic performance improved following participation in the program.

Abstract Study Objective: The objective of this study was to develop and evaluate the effectiveness of a schoolbased sleep education program aimed at improving the sleep and academic performance of school-age children. Methods: Using a community-based participatory research approach, we created a school-based sleep education program, "Sleep for Success"™ (SFS), composed of four distinct modules that addressed the children; their family and community; the school staff; and decision-makers within the school setting. Implementation was carried out in three elementary schools. Seventy-one students participated in the evaluation of the program. The effectiveness of the SFS program was evaluated using non randomized controlled before-and-after study groups (intervention and control) assessed over two time points (preand post-program implementation). Before (baseline) and after implementation, sleep and academic performance were measured using actigraphy and report card marks, respectively. Results: In the intervention group, true sleep was extended by 18.2 minutes per night, sleep efficiency improved by 2.3%, and sleep latency was shortened by 2.3 minutes and report card grades in mathematics and English improved significantly. No changes were noted in the control group. Conclusion: Participation in the sleep education program was associated with significant improvements in children's sleep and academic performance. Key words: Sleep, intervention, school-aged children, academic performance

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2 INTRODUCTION Low academic achievement in children is a common and serious problem that affects a large number of students.1,2 School outcomes largely determine long-term social and economic success, and a successful start to formal learning in school is formative to these outcomes.3,4 Insufficient or poor quality sleep is a significant risk factor for poor academic performance,5-9 as they affect cognitive processes that underlie academic performance,10-16 such as executive functions,17,18 memory19 and attention.9 Previous research efforts have sought to promote good sleep habits and extend sleep durations among adolescents in light of the delayed circadian timing associated with the onset of puberty and the bedtimedelaying psychosocial factors seen in this age group.20 However, a sizeable proportion of elementary school children sleep in average 8 hours24 which is significantly less than the recommended 10 hours per night.21,22 In a large survey, 27% of school-aged children were reported to obtain fewer hours of sleep than their parents/caregivers thought they needed,23 and a recent objective study using wrist actigraphy showed that children ages 4-10 years slept less than the recommended amount of sleep per night.24 Our work seeking to promote good sleep habits and extend sleep duration has focused on younger children for several reasons, including: 1) sleep deprivation in pre-pubertal children is likely to be caused by lifestyle habits and culturally normative bedtimes, and thus may be addressed by sleep education programs that target lifestyle choices; 2) school-age children can suffer from significant sleep deprivation, and will therefore benefit from acquiring healthier sleep habits as well as increased and improved sleep; 3) school-age children are more receptive to guidance from adult figures (e.g., parents and teachers), and are therefore more likely than adolescents to internalize the healthier sleep habits promoted by a schoolbased sleep education program; 4) developing healthy habits at a young age has been shown to create a foundation for integrating these habits into daily life in later years, suggesting that early education on the importance of sleep could set the stage for an easier transition to adolescence. Schools are ideal venues for prevention and intervention programs as they reach large segments of the youth population, provide a platform for health education and promotion,25 and can play an active role in encouraging children to adopt and maintain a healthy lifestyle. It has been shown that using the preexisting infrastructure of the educational system can offer a cost-effective route for delivering healthpromoting programs.26,27 Despite the critical importance of sleep in the daytime functioning and health of elementary school students, and the high prevalence of sleep deprivation among school-age children, the topic of sleep is not addressed in most school health curricula. Only one school-based sleep intervention for elementary school has been reported28 but there is no information regarding its effectiveness as the study did not use objective sleep measures or outcome measures pertaining to the potential impact of the program on daytime functioning. The other reported efforts in sleep education/promotion have focused on school-based interventions for adolescents,29-40 and have suffered from multiple limitations, including the use of knowledge (not actual sleep behavior) as an outcome measure,36-40 the lack of objective measures of sleep,30-36,38,40-42 and the lack of relevant secondary measures, such as academic performance29,30,32,35,36,38,42 (and see 41,43,44). To address the problem of insufficient sleep in school-age children, we developed and evaluated a schoolbased intervention designed to increase children’s total sleep time. This program, “Sleep for Success™” (SFS), was developed through a partnership between a team of researchers from McGill University and a team of educators and communities served by the Riverside School Board (RSB), Quebec. The educational program involved a 6-week classroom curriculum for children, plus tools aimed at eliciting the involvement of parents and teachers. This report describes the results stemming from the implementation of SFS. Page 3 of 18

3

The primary goal of this study was to evaluate the impact of SFS on objective measures of sleep duration, efficiency and latency in healthy, typically developing school-aged children. The secondary goal was to examine changes in report-card grades following students’ participation in this sleep promotion program. We hypothesized that the sleep and academic performance of children in the intervention group would improve compared to baseline following the implementation of SFS, whereas children of the control group would show no change over the study period. METHODS Participants A total of 192 students participated in the program activities. Of them, 74 (33 boys and 41 girls, aged 7-11 years [mean = 8.46, standard deviation (SD) = 1.8]) agreed to participate in the study and completed all measures at both time points. A participant was excluded if he/she: 1) had a history of psychiatric illness, developmental disorder, learning disability, or psychosis that might affect academic performance; 2) reported a sleep disorder; or 3) had a medical or psychiatric condition that might interfere with sleep. Based on these criteria, three children were excluded: two with attention-deficit hyperactivity disorder (ADHD) and one with asthma. Of the 71 remaining participants, 46 children (23 boys, 23 girls) participated in the intervention and 25 (8 boys and 17 girls) comprised the control group. The participants were recruited from three elementary schools of the RSB, which governs the public education of the English-speaking population of Montreal’s south shore. These schools use the same educational curricula, apply the same grading systems, and work under the same educational requirements of the Ministry of Education of Quebec. Two schools agreed to participate in the sleep intervention program, and the third school agreed to act as a control. Teachers invited parents to participate in the study via flyers that described the sleep promotion program (SFS). Parents who responded to these flyers were contacted for further screening. The study was approved by the Research Ethics Board of Douglas Mental Health University Institute (Montreal, Canada) and the Research Ethics Board of the Riverside School Board. Informed consent was obtained from the parents of all participants. Most of the participants were Caucasian (71.4%), with the remainder classified as Mixed Ethnicity (14.3%), Asian (7.2%), Hispanic or African-American (7.1%). All participants spoke English as their first language. The majority of children (93%) came from families in which the parents were married. Of the remaining children, 4.3% came from families in which the parents were separated or divorced, and 2.74% came from families with a single mother. In terms of education, 66% of the mothers and 43% of the fathers had post-graduate educations, 20.56% of the mothers and 34.28% of the fathers had college-level educations, and 13.44% of the mothers and 22.72% of the fathers had high school educations. Regarding income, 6.2% of the households had annual combined incomes < $25,000, 23.3% had annual incomes of $25,000–$65,000, 22.4% had annual incomes of $65,000–$95,000, and 48.1% had annual incomes > $95,000. Design The study aimed to test the effectiveness of “SFS”™ using non randomized controlled before-and-after study groups (intervention and control) assessed over two time points (pre- and post-program). The primary outcome measures were actigraphic sleep measures, and the secondary outcome measures were report card grades.

Procedure Page 4 of 18

4 In the present study, we used a collaborative approach known as Community-Based Participatory Research (CBPR) to develop our sleep-education program.45 Our partnership included researchers, school board administrators, teachers, educators, parents and students. Following the principles of CBPR, we built on the strengths and resources within the community, facilitated a collaborative, equitable partnership in all phases of the research, and fostered co-learning and capacity building amongst all partners.46 By using CBPR to develop “SFS’™ program, we were able to: enhance the relevance of the data and its application by all partners involved; bring together partners with excellent skills, knowledge, and expertise to address the importance of sleep in youth; and enhance the quality, validity, sensitivity, and practicality of our sleep. The programs included the following 4 modules: Sleep Knowledge and Education, which empowers students to make healthier choices; Family and Community Involvement, which encourages parents and children to discuss sleep in the context of a balanced lifestyle; Sleep Promotion for Staff, which empowers staff to practice balanced and healthy lifestyles, and thus lead by example; and Sleep-friendly School Environment, which encourages school principals to assess their school’s policies, curricula, workload, and activity schedules in order to identify modifiable factors that could be targeted in order to support student’s healthy sleep. Sleep Knowledge and Education Module: The topics covered in the program included the barriers to proper sleep, good bedtime routines, proper sleep hygiene, the consequences of poor sleep, the benefits of proper sleep, and the importance of sleep as a critical part of a healthy lifestyle. To ensure that the program was developmentally appropriate, three parallel versions of the “SFS”™ program were developed: first and second graders were introduced to a character named Sleepy Steven; third and fourth graders were introduced to superheroes; and fifth and sixth graders were introduced to the Critical Sleep Investigators. These versions of the program were similar in content and approach, but used different ageand stage-appropriate narratives and cartoons. The material was developed and taught using an experiential learning approach, which is an educational approach that provides students with competencies needed for real-world success by addressing realworld problems and situations through teacher-directed and –facilitated learning.47-49 Reflection on learning during and after one’s experiences is another integral component of the learning process as it leads to analysis, critical thinking, and synthesis.50-52 Consistent with this approach, sleep-related experiences were chosen for their learning potential, such as whether they would: provide opportunities for students to practice and deepen emergent skills pertaining to healthy sleep practices; expose students to novel and unpredictable situations that support new learning; and allow students to learn from the natural consequences, mistakes, and successes experienced by the characters and/or the child him/herself during participation in program activities. Throughout the experiential learning process, the students actively engaged in posing questions, investigating, experimenting, being curious, solving problems, assuming responsibility, being creative, constructing meaning, taking initiative, making decisions, and being accountable for the results. When learners are engaged intellectually, emotionally, socially, and/or physically, they perceive that the learning task is authentic. In our program, the classroom and home environment both served as settings for experiential learning through embedded activities, such as guided inquiry, simulations, experiments, and art projects. By engaging in formal, guided, real-world experiences, students deepened their knowledge regarding sleep and its impact on their daytime performance through: repeatedly acting and then reflecting on this action; developing skills pertaining to improved sleep behavior (e.g., sleep hygiene) through practice and reflection; constructing new understandings when placed in novel situations; and extending their learning by bringing their outside experiences back to the classroom (For an example of this, see: Sleep Squad Movie53). Page 5 of 18

5 In order to allow teachers to integrate the program activities into their regular teaching activities, rather than requiring them to add additional teaching time to implement the program, each program activity was designed so that it could be used to teach skills required by the Ministry of Education of Quebec. Family and Community Involvement: Parental involvement was encouraged in several ways, including: 1) brief, point form letters were sent home following each activity, offering a short overview of the activities completed in class, a brief description of the next upcoming activity, and suggested topics for discussions between parents and children; 2) parental information sessions took place in the schools during parentteacher interview evenings; and 3) parents’ active participation in the program’s homework activities. Sleep Promotion for Staff: School staff attended a workshop regarding pediatric sleep and the role of sleep in health and academic performance. This was offered as a part of the teachers’ activities on their schoolboard mandated pedagogical day. Sleep-Friendly School Environment: To encourage school principals to incorporate “sleep-friendly” practices into their schools (e.g., by assessing/adjusting workloads and extracurricular activity schedules), each principal was individually interviewed to assess his/her attitude and knowledge regarding sleep, and to brainstorm potential ways to support healthy sleep. Training. Teacher training was conducted by a Master’s level trainer who was experienced in “SFS’™ instruction, as well as the RSB school-board liaison, a certified teacher and a senior Physical Activity and Health Consultant who participated in all stages of developing and implementing the program. The training began with an explanation of the scientific and practical rationales of the program, and then moved on to familiarize the teachers with the Teacher Activity Guide. The guide, which was developed collaboratively by teachers and researchers, provided a step-by-step explanation of the utilized activities and materials. Teachers implemented the program according to the manual, and kept in close contact with the project coordinators. Implementation. Six interactive classes (each 2 h in duration, given over a 6-week period) were offered during school time by the students’ homeroom teachers. Since the children and parents were familiar with the implementing teachers), a natural rapport and high level of trust/communication were maintained during implementation of the program. Evaluation. Two weeks prior to the beginning of program implementation, the teachers sent each enrolled child home with a package containing an actigraph (see description below), a sleep diary, and questionnaires. Parents were instructed to provide their child’s most recent report card and to attach the actiwatch to the child’s non-dominant wrist at bedtime for 4 week nights. They were asked to keep a diary of their child’s daily bedtime and wake time (sleep log) during the same period. Sleep was monitored on weeknights during the regular academic year, excluding school holidays. Parents were also asked to complete a detailed questionnaire regarding their child’s health and their socio-economic status (SES). The materials in the first package were collected prior to program implementation. After the last program activity was completed, the teachers distributed a second round of packages containing actiwatches, sleep diary and questionnaires. Again, the parents were instructed to attach the actiwatch to the child’s nondominant wrist at bedtime for 4 week nights, to keep a diary of their child’s daily bedtime and wake time (sleep log) during the same period, and to provide the child’s post-intervention report card. Parents of children in the control group completed the evaluations (questionnaires and actigraphy) and provided the children’s report cards at the same time as the intervention group. No intervention was offered to this group during the experimental period, although they were put on a waiting list to receive the intervention in the future. Page 6 of 18

6 Measures Sleep Assessment by Actigraphy. Nighttime sleep was monitored by actigraphy, which uses a wristwatchlike device (AW-64 series; Mini-Mitter, Sunriver, OR, USA) to measure movement. Actigraphic sleep data were recorded at 1-min epochs, and the Actiware Sleep 3.4 software (Mini-Mitter) was used to score sleep. Actigraphy has been shown to be a reliable method for evaluating sleep in the studied age group, and the Actiware Sleep software was previously validated and shown to have a high correspondence with polysomnographic measures.54-57 The total sum of the activity counts was computed for each 1-min epoch. If the sum exceeded a threshold sensitivity value of the mean score during the active period ⁄45, then the epoch was considered wake. Otherwise, the epoch was considered sleep. The sleep-log-reported bed- and wake times were used as the start and end times for the analyses, and were set by the researcher based on the sleep log and actigraphic data. Sleep onset and sleep end were calculated by the software. The actigraphic sleep measures used in this study included parameters pertaining to estimated and actual time spent asleep during the night, along with sleep efficiency, and sleep latency. Actigraphic data were analyzed using sleep software (AW64 series, Mini-Mitter), and included the following parameters: (a) Sleep Time—the sleep period; (b) True Sleep Time— the amount of time between Sleep Start and Sleep End, scored as sleep according to the Actiware-Sleep algorithm; (c) Sleep Efficiency— the percentage of time in bed spent sleeping; (d) Sleep Latency— the amount of time taken from bedtime until the subject falls asleep. These measures were averaged over the four nights, allowing us to examine the children’s habitual sleep patterns. Daily Sleep Logs. Bedtimes and wake times were taken from sleep logs that were maintained by the parents. Academic Performance. Parents were asked to provide a copy of their child’s report card for the semesters preceding and following the implementation of the SFS program. Grades were given on a scale between 0 and 100. Given the previously established association between sleep and grades in Mathematics, Languages58-61 and physical activity.62-64 we focused on these measures. Demographics and Screening Instruments Socioeconomic Status (SES). Information regarding education, marital status, and household income was collected through a background questionnaire. Two different markers were used to determine SES: combined annual family income and maternal education. Household income was taken as the sum of the annual incomes received by all members of the household from all sources. This measure was selected based on the recommendation of Daly et al..65 Parental education was examined because strong links have been found between the parents’ educational attainment and their children’s achievements in school.66-69 A principal component analysis (employing Varimax rotation) was used to aggregate these measures into a reliable index of familial SES. This analysis produced a one-factor solution that accounted for 72% of the variance (eigenvalue, 1.44) and was weighted by household income and maternal education (factor loadings 0.85 and 0.84, respectively). It was therefore termed SES. Health Information. Health information was collected using a detailed questionnaire that asked parents for specific information regarding their child’s medical and psychological condition, potential sleep disorders, any present or past diagnoses, the lengths of any illnesses, and the use of any treatments or medications. Data Analyses Demographics (SES, ethnicity), behavioral components (i.e., symptoms of emotional or behavioral issues), sleep patterns, and academic characteristics were considered to be dependent variables and were compared between the intervention and control groups using either one-way analyses of variance Page 7 of 18

7 (ANOVAs), multiple analyses of variance (MANOVA) or χ2 analysis, depending on the nature of the data. To examine the impact of the intervention on sleep and academic performance, parallel mixed design multivariate analyses of covariance (MANCOVAs) with Time (Baseline, Post-Intervention/PostWaitlist) as the within-subject factor, Group (Intervention, Control) as the between-subject factor, and age as a co-variate were used to compare changes in sleep and academic performance between SFS program participants and control students. Scheffe’s post hoc tests were conducted to identify the sources of the differences. IBM SPSS Statistics Version 22.0 for Windows (IBM, Armonk, NY, USA) was used for all statistical analyses. P-values < 0.05 were considered to indicate statistical significance. RESULTS Demographic, Behavioral, and Biological Characteristics No significant between-group difference was found for reported race, or SES. The race distributions were similar between the groups. However, there was a larger proportion of girls in the control group compared to the intervention group (χ2 = 3.57, p < 0.05). We therefore conducted MANOVAs to examine potential sex differences in the sleep measures and report card marks. No significant difference was found on any examined measure. Sleep Before and After Implementation of SFS Table 1a presents the means and SDs of the actigraphic sleep measures obtained from children in the intervention and control groups at baseline (i.e., pre-intervention) and the end of the experimental period (i.e., post-intervention). The average sleep duration at baseline was 9.48 hours (SD = 58 min). A MANCOVA conducted to assess between-group differences in sleep at baseline revealed no significant main effect. The mixed-design MANCOVA conducted to determine differences in actigraphic sleep measures obtained before and after the intervention revealed that there was a significant Time x Group interaction (F65,4 = 3.72, p < 0.009), with sleep measures improving in the intervention group compared to, whereas the control group showed no such change. The partial eta-squared (η2 = .18) was of large size. Univariate post hoc analyses showed that children in the intervention group had longer true sleep time (F1, 69 = 4.8, p < 0.03), higher sleep efficiencies (F1, 69 = 4.7, p < 0.03), and a shorter sleep latency (F1, 69 = 12.53, p < 0.001) at the end of the experimental period compared to baseline, whereas no difference was found in the control group compared to baseline. Academic Performance Before and After Implementation of SFS The means and SDs of the report card grades (in Mathematic, English and Physical Activity) of children in the intervention and control groups before and after the intervention are presented in Table 1b. A MANCOVA conducted to assess between-group differences in report cards marks at baseline revealed no significant main effect (F3,67 = 0.7, p > 0.05). A mixed-design MANCOVA, which was conducted to determine differences in report card-grades before and after the experimental period, revealed that there was a significant Time x Group interaction (F4, 66 = 8.85, p < 0.001), with academic performance improving over the experimental period in the intervention group, whereas the control group showed no such change. The partial eta-squared (η2 = .16) was of large size. Univariate post hoc analyses showed that grades in Mathematics and English were significantly improved at the end of the experimental period compared to baseline (F1, 69 = 8.55 , p < 0.004, F1, 69 = 4.58, p < 0.05) and grades in physical education were marginally improved (F1, 69 = 3.38, p < 0.07) in the intervention group. In the control group, Mathematics grades deteriorated in the control group, whereas the other grades were unchanged. DISCUSSION

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8 Our main findings are that participation in this sleep education program yielded improvements in objective measures of sleep and report card grades. To our knowledge, this is the first intervention to document improvements in sleep duration in elementary school children using objective measures of sleep. Specifically, to our knowledge this study is the first to: 1) use objective measures of sleep to determine the impact of a sleep-education program on the sleep of school-age children; 2) examine the impact of such a program on sleep duration and sleep efficiency; 3) use academic performance outcome measures to assess the impact of such a program; 4) use community-based participatory research to develop a sleep intervention for children; 4) use an experiential learning approach in the design of such an intervention; 4) tailor the intervention carefully to the developmental learning styles of the different ages included in the intervention; and 5) include teachers, administrators, parents and children in the intervention program. Following participation in our school-based sleep education program, the children’s true sleep was extended by an average of 18.2 minutes per night (cumulative average extension of 5 nights x 18.2 minutes= 91 minutes) their sleep efficiency improved by 2.3%, and their sleep latency was shortened by 2.3 minutes. These findings indicate that a sleep education program focused on school-age children, their families, and their school environment can successfully increase students’ sleep duration and improve their sleep efficiency. A sleep duration increase of a similar magnitude was previously associated with improved daytime functioning among children in studies testing the impact of cumulative moderate sleep extensions on children’s daytime behavior and performance.70,71 For example, one study showed that a 27-min sleep extension yielded improvements in daytime sleepiness, emotional lability, and restlessimpulsive behaviors in elementary school children.70 In another study, a sleep extension of 30 min or more improved children’s vigilance, motor reactions on a simple reaction-time task (often used to assess sustained attention), and functioning in the school environment, compared to children subjected to sleep restriction or no change.71 We further found that sleep efficiency and report card grades were improved following participation in the program. These findings are consistent with those of our previous study showing that sleep efficiency was significantly associated with children’s academic performance in Mathematics, English and French.61 The results of the present study and previous investigations, collectively, suggest that sleep education programs can achieve measurable and significant improvements in children's daytime functioning by extending their sleep duration and improving their sleep efficiency. In terms of academic performance, participation in the intervention was associated with improved grades in English and Mathematics as well as a marginally improved grade for physical education, compared to baseline. These findings provide empirical evidence, in an ecologically-valid setting, that a moderate, cumulative sleep extension can have a positive effect on school-age children. There has been much debate regarding the “right” amount of sleep for children and whether it is true that children generally do not get enough sleep.72 However, all sides of the debate agree that empirical evidence is needed to support sleep recommendations for typically developing children. It has been suggested that the optimal sleep duration should be empirically determined based on titrations of sleep duration performed in an ecologically valid context (i.e., outside the laboratory) with careful measurement of outcomes.73 Consistent with this notion, the present study assessed whether, and to what extent, typically developing children with no reported sleep disorders could extend/improve their sleep, as well as the impact of such changes on their academic performance. Actigraphy indicated that the assumed sleep duration based on parental sleep logs regarding bedtime and wake up time at baseline was 9.55 hours, which is within the recommended range. True Sleep Time, however, was around 7.5 hours. This finding is consistent with other wrist-actigraph-based studies showing that school-age children slept an average of 8 per night.24 The discrepancy between time in bed and the true sleep duration suggests that sleep deprivation in school-children might be overlooked when using parental reports, which are based on the amount of time children spend in bed rather than their true sleep time. These findings, combined with the performance changes we observed following the sleep education program (and subsequent Page 9 of 18

9 improvements in sleep), are consistent with the presence of a discrepancy between the recommended amount of sleep and children’s true sleep patterns, as well as support the notion that children do not get the amount of sleep that is optimal for daytime performance. Two meta-analyses examined the impact of educational interventions aimed at improving academic performance or school readiness. One included 123 quasi-experimental and experimental studies of U.S. center-based educational interventions,74 while the other reviewed 30 studies of non-U.S. early educational programs, mostly in low-income countries.75 The U.S. meta-analysis found average effects of 0.23 standard deviation (SD) for cognition. The international meta-analysis examined the results from relatively rigorous studies, and found an average effect for early educational interventions of 0.35 SD for cognition. In the present study, we examined the differences in report card grades of students in the intervention group using the approach taken by Barnett,76 and found that the children’s performances improved 0.16 SD in Mathematics and 0.20 SD in English. All other things being equal, this shows that specific academic gains can be achieved by improving sleep. This relatively inexpensive intervention could prove to be a cost-effective strategy to improve children's sleep and academic performance during the elementary-school years, when educational efforts can have a significant impact on a child’s sleep habits and create a foundation for future health habits and academic performance. Previous studies conducted with school-age children and adolescents found that there are multiple barriers to the success of an intervention such as ours, including difficulties in: engaging teachers, schools and families in the education program;29,30,35,39,77 persuading teachers to add teaching time for the sleep education program or integrate it into their existing teaching time;32,78 and obtaining behavioral changes pertaining to sleep beyond changes in knowledge about sleep.31 In all of these previous studies, the researchers developed the utilized sleep education programs. In most cases, the researcher(s) delivered the intervention themselves or (in a few cases) personally trained teachers to deliver the intervention. In the present study, we used a collaborative approach known as Community-Based Participatory Research (CBPR) to develop our sleep-education program.46 By using CBPR to develop the “SFS’™ program, we were able to: enhance the relevance of the data and its application by all partners involved; bring together partners with excellent skills, knowledge, and expertise to address the importance of sleep in youth; and enhance the quality, validity, sensitivity, and practicality of our sleep education program by involving the community in its design. This yielded an effective program that successfully improved the sleep and performance of children in the community. Based on input from the community, and in collaboration with relevant experts, we developed a program that uses teaching methods that are developmentally appropriate and match the teachers’ preferred style, enabling them to seamlessly integrate our intervention into their regular teaching time. This approach allowed us to avoid some of the barriers reported in previous studies, and greatly facilitated the implementation and the evaluation of the program. Future studies that seek to integrate sleep education into existing curricula might benefit from using CBPR, as described in the present study. It has been proposed that sleep behavior in children should be viewed within a biopsychosocial framework in which the structure, organization and regulation of sleep are governed by intrinsic biological processes that interact with cultural values, parental beliefs, and social systems.79 However, the previously reported sleep education programs have focused almost exclusively on trying to change the students’ sleep habits, with only a few programs also attempting to engage parents. 35,80,81 No previously reported program made an effort to address the social systems and cultural values that regulate the children’s sleep habits. Therefore, in developing and implementing the SFS program, we sought to affect students within the context of daily life and engage the primary external regulators of their sleep (i.e., parents)by simultaneously addressing their knowledge, habits, family environment, social systems and cultural values (represented by the teachers and the school administrators). Given the integrative nature of the intervention, we cannot separate out the unique impact of each module, making it impossible to Page 10 of 18

10 determine to what degree each aspect contributes to shaping children’s sleep patterns. Future studies could compare and contrast the contributions of each module. Limitations and Future Directions This study has several limitations. Due to practical challenges, we used a non-randomized trial to allocate schools to the intervention vs. control conditions. Although the program participants were the students, their parents had to participate in evaluating the program; therefore, parents were approached in all schools. However, the schools in which the actual intervention was implemented yielded a higher response rate, which may have biased the sample. For example, responding parents may have been more highly motivated or concerned about their child's sleep. In addition, families that participated in all stages of the research may have been more engaged than families that did not. Although our study did not include a formal assessment of parents’ and teachers’ changes in knowledge and attitude towards sleep, open interviews indicated that these individuals learned and gained a deeper appreciation of the importance of sleep. Due to limitations in our resources, we did not perform any follow-up to measure how long the changes in sleep were sustained following the intervention. Future studies should include both a booster session and follow-up measurements. The participants had no reported sleep problem, but the presence of sleep disorders cannot be completely excluded because of the lack of comprehensive physiological measures of sleep. Future studies would benefit from the use of both polysomnography and actigraphy to identify students with sleep disorders and investigate the associations between changes in specific sleep stages and improved cognition in healthy school-age children. Nevertheless, the present study offers several important strengths, including: the use of objective sleep measures; the inclusion of academic performance outcomes; a novel focus on producing a developmentally appropriate program; the use of particularly effective teaching methods; and a larger sample size than previous studies on sleepeducation programs. Although some investigators have debated the contention that children do not get the sleep needed for optimal performance and health, our findings, together with previous work, show that many school-age children obtain insufficient sleep, and that this has a significant negative impact on daytime performance. Studies such as the current one demonstrate that small, cumulative improvements in sleep can have detectable effects on the learning capacity and performance of school-age children, thereby supporting the introduction of sleep curricula into schools.

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16 Table 1a Sleep Variables as Measured by Actigraphy Before and After a School-Based Sleep Intervention Program in the Intervention Group and the Control Group (N = 70)

Intervention Group (n = 45) Pre-Intervention Post-Intervention M(SD) M(SD)

Control Group (n = 26) Pre-Intervention Post-Intervention M(SD) M(SD)

Sleep Total Sleep Duration (min)

566.41(62.06)

573.99(61.37)

573.57(49.41)

569.01(38.50)

True Sleep (min)

455.7 (67.48)

473.9 (59.17)

493.36(46.64)

481.61(36.48)

76.76(9.69)

79.09(7.37)

82.35(4.12)

81.68(3.62)

Note. = mean;(min) SD = standard deviation. SleepMLatency 18.92(13.00)

Sleep Efficiency (%)

16.60(12.09)

14.89(10.28)

21.83(15.94)

Page 17 of 18

17 Table 1b Report Card Grades in Four Subjects Before and After a School-Based Sleep Intervention Program in the Intervention Group and the Control Group (N = 70) Intervention Group (n = 45) Control Group (n = 25) Pre-Intervention Post-Intervention Pre-Intervention Post-Intervention M(SD) M(SD) M(SD) M(SD) Report Card Grades (%) Physical Education

78.9(6.42)

81.70(5.27)

81.33(6.47)

80.3 (6.13)

Mathematics

77.1(12.79)

79.50 (11.74)

78.21(13.66)

76.08(10.80)

English Language Arts

75.2(10.78)

77.58(10.82)

77.75(8.35)

78.40 (9.18)

Note. M = mean; SD = standard deviation.

Page 18 of 18