To the editor:

As pediatricians and scientists at Brown who have dedicated their careers to improving the health of Rhode Island’s children via both clinical care and research, we would like to clarify the research on later school start times, as the school committee has stated that they are basing their decision to move forward with this initiative on the science behind it. Additionally, the term “medically recommended later school start times” is being used in communications, and we feel this is potentially misleading to many.

Simply stated, rigorous evidence to suggest that changing the start times will be beneficial for kids does not exist. The American Academy of Pediatrics (AAP) and other organizations have put out policy statements on the topic. Policy statements are expert opinions based on more or less strong evidence, and organizations are known to modify or rescind statements when new evidence emerges, opinions change or it becomes clear that the science behind the old statement is incorrect. For example, the AAP statements on screen time and on when to introduce foods that may cause allergies have been changed significantly in recent years. In some cases, the science behind the recommendation is irrefutable, such as car seats, bicycle helmets, vaccinations and “back to sleep.” In other cases, there is more gray area, as rigorous scientific evidence on the exact best approach is not available. How long to breastfeed and when to introduce solid foods are in this category. So is when to start school in the morning.

Cochrane reviews (called meta-analyses) are the gold standard in unbiased reviews of the entire existing body of research in an area of study. A Cochrane review on the research on later school start times was performed in 2017 (and was not listed on the most recent BPS school start time medical literature website). Out of 1,890 potentially relevant documents, only 11 studies were considered unbiased and relevant, representing 297,994 research participants. And ultimately, no evidence for the benefits of later school start times was found.

Highlights of the conclusions of the Cochrane review include: “Unfortunately, this review cannot provide compelling evidence for these efforts, given the small and inconsistent evidence base that currently exists… the low quality and scarcity of evidence means that we could not definitively determine the effects of later school start times… Because of the low quality of the studies included, though, we cannot make recommendations concerning delayed school starts at this time… Although later start times may be a possible consideration for education officials, it may be premature to base school policy or practice decisions on these findings given the limited evidence to date. Indeed, the current best available evidence does not permit firm conclusions regarding the potential benefits or harms of later school start times.” (Original publication: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6483483/pdf/CD009467.pdf)

While the School Committee drew our attention to two additional studies that have been published since the Cochrane review, adding those two and their few hundred participants to the 1890 studies with 297,994 participants already assessed, is the proverbial drop in the bucket. It is highly unlikely that, had they been included in the meta-analysis, they would have significantly moved the needle on the conclusions, which still leaves us with no high quality evidence suggesting that later start times have positive effects and lack negative effects.

In summary, the question isn’t just whether the School Committee should insist on later school start times. The question is also whether the School Committee should insist on an initiative when there is no rigorous medical evidence for it and the downstream effects are unknown, when the educators who are tasked with teaching our children are opposed to it, when the community voted to cut the school budget by the exact amount that this initiative will cost, and when this initiative will lead to programs being cut that are meaningful to our children. As we are moving closer towards this initiative, we are moving farther away from everyone’s wellbeing. And that is distressing.

Elisabeth McGowan MD

Barrington

Beatrice Lechner MD

Barrington

Betty Vohr MD

Barrington