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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

Return to Learning Team

The AAP recommends that pediatricians work collaboratively with a mulit-disciplinary team consisting of the concussed student and their family, school and other medical personnel and individuals at the child's school responsible for both the student's academic schedule and physical activity, to ease the transition back to the school environment and facilitate reocovery. 


Multidisciplinary Team to Facilitate "Return to Learn"
Team
 Members  Role/Responsibilities
Family team
Students, parents, guardians, grandparents, peers, teammates, and family friends
  • Enforce rest and reduce stimulation to the student during recovery
  • Parents to decide when the student can return to school;
    • If student athlete experiences symptoms enough to affect his/her ability to concentrate or tolerate stimulation for even up to 30 minutes, student should likely remain at home, where he/she may consider light mental activities, such as watching TV, light reading, and interaction with family, until they provoke symptoms, with computer use, texting, and video games at a minimum;
    • When student can tolerate cognitive activity or stimulation comfortably for approximately 30 to 45 minutes (which the report admits is an "arbitrary cutoff"), parents may consider returning the student back to learning, either through home tutoring or in-school instruction with programming adjustment as needed;
  • As concussion symptoms improve, parents work with school academic team on increasing mental and social activities, as tolerated by the student (such as allowing child to attend social gatherings, watch a game, or return to driving), involving medical team only as needed, apart from follow-up visits;
  • In first few weeks after concussion, parents to follow up with school and their child to assess whether academic adjustments are occuring to minimize worsening of student's symptoms during early recovery;
  • Parents need to sign release of information for school personnel to coordinate adjustments that may be needed as recommended by the primary care provider.
Medical team
Emergency department, primary care provider, concussion specialist (primary care sports medicine physicians, neurologists, neurosurgeons, as examples), clinical psychologist, neuropsychologist, team and/or school physician
  • Pediatrician identifies "point person" or case manager to contact at school, and identifies point person in the pediatrician's office to communicate during the RTL process, obtaining the necessary FERPA and HIPAA permissions;
    • Ideally, at least 1 person on this team is communicating with 1 person from the other teams;
    • Reduces likelihood of a pediatrician's office receiving frequent phone calls from many individuals about same situation.
  • Physicians learn educational terminology to assist them in being precice in what they are requesting of schools, including difference between
    • "academic adjustments" (nonformalized adjustments made to student's environment during the typical 1- to 3-week recovery period that do not jeopardize the curriculum or require alterations in standardized testing)
    • "academic accommodations" (used to address longer term needs beyond 3 weeks, which may include standardized testing arrangements, extra time on work, changes in class schedule, and access to grade-level curriculum, but still within the context of regular education and may be formalized in a 504 plan); and
    • "academic modification" (used when considering more prolonged and more permanent changes to an educational plan, necessitating special education with needs specified in an IEP.  [Note: this nomenclature is new; it remains to be seen whether it will prove to be meaningful and useful distinctions for schools and health care practitioners across the U.S. to use.]
  • Pediatrician lists restrictions and adjustments on note to school at each patient follow-up visit and during interim, if needed;
  • Gather data from other team members needed to aid in deciding when to provide the written authorization now required in almost all states before a concussed student-athlete can begin safe progression back to increasing physical activity leading to a return to sports.
  • For students with symptoms that last longer than three weeks, pediatrician provides school with medical documentation based on persisting signs and symptoms that might significantly limit a child's ability to access full instruction, and referal to a concussion specialist should also be considered, if not already initiated. 
School academic team
Teacher, school counselor, school psychologist, social worker, school nurse, school administrator, school physician
  • Recognize that most students will likely return to classroom while symptomatic from their concussion, and that return requires individualized approach (no "cookie cutter");
  • In early phases of a concussion, coordinates return of student to cognitive exertion and helps facilitate appropriate level of academic adjustments necessary to reduce or eliminate symptoms. Most interventions can be made to general education classroom by general education teacher with minimal support and check-ins with other members of academic team;
  • When the student returns to school, observing which classes exacerbate symptoms to allow for further adjustments to help reduce making symptoms worse;
  • Teachers encouraged to pick and choose academic adjustments most amenable to their class teaching style and content and most appropriate for the phase of recovery of the concussion on the basis of a child's tolerance;
  • Teachers and other academic team members reassess progress at weekly intervals to determine effectiveness and continued need for adjustments, communicating directly with student in a private setting.
  • In cases of prolonged symptoms, activate system for accommodations (504 plan) for students expected to have temporary interference with learning or modifications (IEP) for students with a classifiable chronic condition;
  • Brain storm and problem solve with family and medical teams about what other interventions may be helpful and decide whether more formalized assessments need to occur; at this level some of the interventions can no longer be easily applied in general education classroom without formal intervention (i.e. Individualized Health Plan, learning plan, or 504 plan).
  • If symptoms remain severe or prolonged (typically longer than 5 to 6 months), more intensive intervention may be needed, potentially including considering more permanent disability, triggering in most school districts their Child Find (a component of IDEA) obligations, providing appropriate testing, and development of an IEP in consulation with the family and medical team. Note, however, that is uncommon for the student with a concussion to need an IEP.   
  • A medical diagnosis of concussion can prompt the school academic team to collect other sources of information and consider developing a 504 plan or IEP, which are governed by different laws. 
School physical activity team
School nurse, athletic trainer, coach, physical education teacher, playground supervisor, school physician
  •  In early stages of the concussion, primary goal is to safeguard student from any further potential injury to the brain (no sports, no PE, etc.)
  • After student no longer needs academic adjustments or  accommodations, begin return to play protocol leading to eventual return to competition.

 

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