Students recovering from a concussion often need academic, environmental adjustments
- Copyright © 2013 by the American Academy of Pediatrics
When a child has a concussion, when should he or she return to school? Is cognitive rest an effective treatment, and how much is required?
While much has been written about returning to play following a concussion, many questions remain about when a child is ready to return to learning. A new AAP clinical report answers these questions.
The report, Returning to Learning Following a Concussion (Pediatrics 2013;132:948-957OpenUrl), picks up where a 2010 clinical report on concussion and return to play left off, said Mark E. Halstead, M.D., FAAP, lead author of both reports and a member of the AAP Council on Sports Medicine and Fitness Executive Committee.
“There is a lot of confusion when we talk about managing concussions and cognitive rest,” said Dr. Halstead, adding that research on the impact of cognitive rest on recovery is limited. “Cognitive rest doesn’t mean kids have to be kept from all mental activity; some can be beneficial,” he said.
The best recovery plans strike a balance between cognitive rest and exertion, and are customized for the individual child, the report indicates. Pediatricians, school personnel and parents all play a key role in helping children recover.
Tune in to child’s needs
“The medical home and the ‘school home’ need to tune in to the individual child’s needs, and tailor a return-to-learn program that is feasible to both the child and the school and is promoting healing,” said Cynthia D. Devore, M.D., FAAP, a lead author of the report and chair of the AAP Council on School Health Executive Committee.
Pediatricians should be prepared to help schools understand the unique recovery needs of children following a concussion. While some schools are accustomed to making these accommodations following a concussion, many have little to no experience with return-to-learn treatment plans, the authors said.
Students should be encouraged to return to school when they can tolerate learning for 30 to 45 minutes at a time, the report said. Upon their return, a variety of adjustments — designed to reduce stimuli or provide cognitive breaks — should be considered depending on the student’s symptoms.
Symptom checklists can be helpful in managing recovery, Dr. Halstead said. For example, if a child is experiencing light sensitivity, teachers could reduce the child’s exposure to computers, Smart Boards and videos or allow the student to wear a hat or sunglasses. A child experiencing headaches could be given frequent breaks, reduced exposure to stimuli that trigger a headache or planned rest breaks in the nurse’s office or other quiet area. The report outlines a variety of strategies that can be used for common concussion symptoms.
Students who are recovering from a concussion should not take standardized tests, Dr. Halstead said. The outcomes often are a poor reflection of the child’s knowledge, and the process can increase symptoms.
Detailed recommendations essential
The best way to help children get the accommodations they need in school is by writing a detailed note rather than just saying they need adjustments, Dr. Halstead said. “My notes have (accommodations) broken down by symptoms.”
Dr. Halstead worked with the Centers for Disease Control and Prevention to create a template pediatricians can send to schools to describe a patient’s symptoms and the accommodations needed (see resources).
Pediatricians can expect a variety of responses from schools to their notes. Dr. Halstead has been working with St. Louis-area schools on return-to-learn plans for about five years. Initially, schools resisted creating plans for kids, but now schools are proactively asking pediatricians what they can do for their students.
It’s often easier to establish concussion-related adjustments for elementary and middle-school students than it is for high schoolers, said Kelsey Logan, M.D., M.P.H., FAAP, contributing author to the report and a team physician for several Cincinnati high schools. The most driven students, both athletically and academically, often are reluctant to take breaks during school, she said.
“I had a 16-year-old girl with pretty severe concussion symptoms who was unwilling to comply with academic accommodations,” Dr. Logan recalled. The student was afraid the accommodations would not be followed and that teachers would penalize her for her injury.
“One of the best things you can do at that point is have a conversation with someone at the school about what’s going on,” Dr. Logan said. “If the school doesn’t understand the limitations the student has … it can be a barrier to recovery and increases the stress the student is under.”
Ultimately, the patient’s parents refused to allow Dr. Logan to contact school officials. After a few days, Dr. Logan said, “she (the student) felt so bad overall, she ended up following some of the recommendations.”
It’s hard for teenaged patients and their parents to understand the recovery process, Dr. Logan said, and often just as hard for schools. “It’s vitally important that you have direct communication with school personnel.”
Guidance for pediatricians
Students who have suffered concussions may need academic adjustments to cope with the school environment.
Because most concussions resolve within three weeks, adjustments often may be made in the classroom without formal written plans.
For symptoms lasting longer than three to four weeks, students may need an assessment by a concussion specialist and accommodations specific to the educational environment.
Students should be performing at their academic baseline before returning to extracurricular activities.
Education of all individuals involved with students who have sustained a concussion is necessary.
REAP Concussion Management Program, www.rockymountainhospitalforchildren.com/sports-medicine/concussion-management/reap-guidelines.htm
Concussions 101 video, www.myfavouritemedicine.com/concussions-101/
Heads Up for Schools, www.cdc.gov/concussion/headsup/schools.html and a fact sheet at www.cdc.gov/concussion/pdf/TBI_Returning_to_School-a.pdf that addresses return-to-learn strategies