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From the American Academy of Pediatrics

Ensure Successful Return To Classroom After Concussion, Says Pediatrics Group

AAP recommends team approach involving family, medical and school personnel to get concussed students back on track in school


Helping a student-athlete make a successful return to learning after a concussion is just as important as ensuring their safe return to sports, and requires a team approach involving parents, health care professionals, and schools, says the American Academy of Pediatrics in an important new clinical report. [1]

"Students appear physically normal after a concussion, so it may be difficult for teachers and administrators to understand the extent of the child's injuries and recognize the potential need for academic adjustments," said Mark Halstead, MD, FAAP, a lead author of the clinical report and also lead author of the AAP's 2010 guidelines for pediatric concussions.[2]

"We know that children who've had a concussion may have trouble learning new material and remembering what they've learned, and returning to academics may worsen concussion symptoms," writes Halstead.

The report said it it was "unfortunate that [so] little attention has been given to academics and learning and how a concussion may affect the young student learner." 

"Every concussion is unique and symptoms will vary from student to student, so managing a student's return to the classroom will require an individualized approach," said Dr. Halstead. "The goal is to minimize disruptions to the student's life and return the student to school as soon as possible, and as symptoms improve, to increase the student's social, mental and physical activities." Sleeping boy at his school desk

Research, the report says, has shown that a school-aged student usually recovers from a concussion within three weeks. If symptoms are severe, some students may need to stay home from school after a concussion. If symptoms or mild or tolerable, the parent may consider returning him or her to school, perhaps with some adjustments, says the AAP.

Students with severe or prolonged symptoms lasting more than 3 weeks (the point at which some experts classify a concussed student as having post-concussion syndrome) may require more formalized academic accommodations, the group says.

Great first step

"Overall, the authors should be commended for providing this educational and informative piece discussing concussion and the effects on students," said sports concussion neuropsychologist Rosemarie Scolaro Moser, PhD, Director of the Sports Concussion Center of New Jersey and a MomsTEAM concussion expert. "Their assertions that concussion management is a team approach, that each concussion is unique, that students need academic accommodations are important public messages. It is a great first step in educating pediatricians about this growing public health concern and their roles in concussion team management," Moser said. 

To that end, the AAP report, not surprisingly, contains a host of specific recommendations for pediatricians, including that they:

  • Assess the concussed student for a more serious structural or neurologic injury;
  • Know how the symptoms of concussion can affect the student in the school setting (see table below), as a thorough understanding of potential problems the student can encounter will help the pediatrician make appropriate recommendations to the school, the student, and student's family;
  • Discuss with patients and parents other potential stressors which may affect symptom reporting, such as:
    • family or relationship problems;
    • pressures from coaches and teammates to return to sports; and/or
    • restriction from participation in important upcoming life events.
  • Employ age-apppropriate symptom checklists serially to follow a student through their recovery and identify areas that might require more targeted interventions.  
    • Because many of the symptoms reported after concussion may not be unique to concussion (for example, some students may have pre-existing depression, chronic daily or intermittent headaches, learning disabilities, or attention deficit/hyperactivity disorder), further inquiry as to the specific nature of the symptoms reported by the student or observed by the parent may be needed.
    • Different symptoms checklists[5] are recommended for students in seventh grade and up (SCAT3) [6] and for kindergarten to sixth grade (Child-SCAT3);[7]
  • Take a careful concussion history to account for any preinjury conditions, especially for those experiencing prolonged postconcussive symptoms, which should be managed concurrently;
  • Prescribe adequate physical and cognitive rest, as appropriate, to help minimize a worsening of symptoms and potentially facilitate a quicker recovery without significant disruption to the student's life;
  • Communicate with other members of the multidisciplinary team on an ongoing, as-needed basis to coordinate and facilitate a concussed student's return to learn (see next section);
  • Counsel concussed athletes on the current recommended return to activity progressions, as outlined in the AAP's 2010 clinical report.[2]

Concussion symptoms: implications for learning 

The report provides helpful information on the potential implications in school for a student experiencing particular concussion symptoms and the kind of adjustments that may be required as a result: 

Sign/Symptom Potential Implications in School
 Potential Adjustments

 

 

Headache

  • Most  common concussion symptom
  • Can distract the student from concentrating
  • Can vary over the course of day
  • May be triggered by various stimuli, such as fluorescent lighting, loud noises, and focusing on tasks
  • Frequent breaks
  • Identifying aggravators and reducing exposure to them
  • Rests, planned or as needed, in nurses office or quiet area

 

 

 

Dizziness/lightheadness

  • May be an indication of injury to vestibular (balance/inner ear) system 
  • May make standing quickly or walking in crowded school hallway challenging
  • Often provoked by visual stimulus (rapid movements, videos, etc)
  • Troubles with various aspects of the school building
  • Allow student to put head down if symptoms worsen
  • Give student early dismissal from class and extra time to get from class to class to avoid crowded hallways

 

 

Visual symptoms: light sensitivity, double vision, blurry vision

  • Slide presentations
  • Movies
  • Smart boards
  • Computers
  • Artificial lighting
  • Difficulty reading and copying
  • Difficulty paying attention to visual tasks
  • Reduce exposure to computers, smart boards, and videos
  • Reduce brightness on screens
  • Allow the student to wear a hat or sunglasses in school
  • Consider use of books on tape
  • Turn off flourescent lights as needed
  • Seat student closer to the center of classroom activities (blurry vision)
  • Cover 1 eye with patch/tape 1 lens if glasses are worn (double vision)

 

 

Noise sensitivity

Troubles with various aspects of the school environment

  • Lunchroom
  • Shop classes
  • Music classes (band/choir)
  • Physical education classes
  • Hallways
  • Organized sports practices [Note: a student-athlete should not return to sports until asymptomatic and off all academic accommodations)
  • Allow the student to have lunch in quiet area with a classmate
  • Limit or avoid band, choir, and shop classes
  • Avoid noisy gyms and organized sports practices/games
  • Consider use of earplugs
  • Give student early dismissal from class and extra time to get from class to class to avoid crowded hallways during pass time

 

 

Difficulty concentrating or remembering

Challenges learning new tasks and comprehending new material:

  •  Difficulty with recalling and applying previously learned material
  • Lack of focus in the classroom
  • Troubles with test taking
  • Troubles with standardized testing
  • Reduced ability to take drivers education classes safely.
  •  Avoid testing or completion of major projects during recovery when possible
  • Provide extra time to complete nonstandardized tests
  • Postpone standardized testing (may require that 504 plan is in place)
  • Consider 1 test per day during exam periods
  • Consider the use of preprinted notes, notetaker, scribe, or reader for oral test taking

 

 

Sleep disturbances

  • Excessive fatigue can hamper memory for new or past learning or abililty to attend and focus
  • Insufficient sleep can lead to tardiness or excessive absences
  • Difficulty getting to sleep or frequent waking at night may lead to sleeping in class
  • Excessive napping due to fatigue may lead to further disruption of the sleep cycle.
  • Allow for late start or shortened school day to catch up on sleep
  • Allow rest breaks

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