Returning to the Classroom

Concussion injuries can directly impact a student's learning ability. Conversely, the cognitive learning process can adversely affect a student's recovery from a concussion. Therefore, concussed students may need varying levels of instructional modifications and academic accommodations during their symptom recovery, particularly early on in the acute stage, but can extend several weeks or months.

Current concussion management guidelines recommend concussed students remain at rest, both physically and cognitively to facilitate their recovery from symptoms. Cognitive rest refers to the reduction in mentally taxing activities, i.e. analytical problem solving, mathematical equation work, focused or prolonged reading, computer use, as well as activities involving saccadic eye movements such as using eyes to track objects, read, and smart-board work. Playing video games, texting, watching TV, and listening to music with earphones may also be discouraged during the symptomatic phase.

Just as concussed athletes follow a stepwise progression for "Return To Play," a progression back to the learning environment is equally important. A "Return To Learn" process emphasizes a collaborative team approach between school administration, school nurses, counselors, teachers, parents, and athletic staff (including a school's athletic training staff when student-athletes are involved). Because concussions occurring in athletics are less prevalent than those occurring on playgrounds, during recreational activities such as biking or skateboarding, accidents at home, falls, and motor vehicle accidents, a Concussion Management Team can be beneficial for recovery and returning all concussed students, athletic and non-athletic, to the classroom.

School staff should be familiar with the signs and symptoms of concussions. Additionally, school staff should know how to monitor students knowingly having a concussion, as well as recognize those possibly having a concussion unknowingly. There is greater concern for how long symptoms last, more so than which ones or how many might exist, but all three elements are important to the proper management of the concussed student.

Signs To Look For After A Concussion

When students return to school after a concussion, school staff should watch for:

  • Increased problems paying attention or concentrating
  • Increased problems remembering or learning new information
  • Longer time needed to complete tasks or assignments
  • Difficulty organizing tasks or shifting between tasks
  • Inappropriate or impulsive behavior during class
  • Greater irritability
  • Less ability to cope with stress
  • More emotional than usual
  • Difficulty handling a stimulating school environment (lights, noise, etc.)
  • Physical symptoms (headache, dizziness, nausea, visual problems)
Symptoms of a Concussion Indicated by the Student
Physical
  • Headache
  • Nausea
  • Vomiting
  • Balance Problems
  • Dizziness
  • Visual problems
  • Fatigue
  • Sensitivity to light
  • Sensitivity to noise
  • Dazed or stunned


Emotional

  • Irritability
  • Sadness
  • More emotional
  • Nervousness
Congnitive
  • Feeling mentally "foggy"
  • Feeling slowed down
  • Difficulty concentrating
  • Difficulty remembering
  • Forgetful of recent information or conversations
  • Confused about recent events
  • Answers questions slowly
  • Asks same question repeatedly


Sleep Related

  • Drowsiness
  • Sleeping less than usual
  • Sleeping more than usual
  • Trouble falling asleep
General Considerations for "Return to Learn" Progression

In most cases, a concussion will not significantly limit a student's participation in school and usually involve temporary, informal instructional modifications and academic accommodations. The "Return to Learn" process encompasses Step 1 of the "Return to Play" progression during the entire time one remains symptomatic. Completion of the "Return to Learn" process precedes the start of "Step 2 - Return to Play" progression.

In approximately 75 percent of cases, recovery from symptoms occurs within seven days, while roughly 90 percent recover from symptoms within 10 days. But nearly 5-10 percent percent of cases may take several weeks or months to recover from symptoms that experience Post-Concussion Syndrome, a chronic condition where symptoms persist long-term.

The school's athletic trainer or other licensed healthcare provider will help guide decisions for the Concussion Management Team about a student's need for and level of modifications and accommodations, or adjustments, and their readiness to resume various school activities.

Symptoms are monitored at regular intervals using a Graded Symptom Scale. Symptom scale scores can remain elevated or increased by exceeding levels of physical and cognitive activity where school activity should then be reduced when symptoms increase as a result. Members of the Concussion Management Team are to help identify triggers that cause symptoms to worsen, and modify school activity accordingly. Thereafter, school activities can be gradually increased as symptoms subside or decrease.

If recovery becomes more prolonged (more than three to four weeks), there should be greater concern for a student feeling isolated or depressed and experiencing anxiety from not attending school, falling behind, and missing out on playing sports and other extracurricular activities. Additionally, a 504 Plan or an IEP may need to be considered for those having prolonged recovery extending beyond several months.

School Accommodation Options Based on Symptom Type
Headaches
Allow to lay head down at desk
Allow frequent breaks
Identify triggers that cause headaches to worsen
Sensitivity to Noise (phonophobia)
No PE, band, chorus, shop class; meet in library
Avoid lunch room; eat in quiet setting
Avoid attending athletic events, gymnasiums
Allow early hall pass to class avoiding loud corridors
Refrain from using cell phone, headphones/ear buds
Sensitivity to Light (photophobia)
Allow to wear sunglasses
Move to area with low-lighting, dimly-lit room
Avoid seating with direct sunlight from windows
Avoid or minimize bright projector/computer screens

Other visual problems

i.e. blurred or double–vision
saccadic eye movements (tracking)
near–point convergence (close–up)

Limit computer use
Reduce/shorten reading assignments
Record lectures, use auditory learning apps
Allow for more listening & discussion vs. Reading
Increase font size on computer screens
Desktop work only
Refrain from texting, video gaming
Refrain from watching TV close–up or from a distance
Concentration or Memory (Cognitive) Problem
Place main focus on essential academic content/concepts
Postphone major tests or participation in standardized testing
Allow extra time for assignments, quizzes
Allow extra time to complete tests, projects
Reduce class assignments, homework
Sleep Difficulties
Allow late start to school
Allow frequent rest breaks

Levels of Instructional Modifications and Academic Accommodations
1
No School (Stay Home)
Three or more ImPACT Summary Composite Scores exceed
RCI
*Exceedingly high Graded Symptom Scale Score, i.e.,
Score: >25-30
Discourage texting, video gaming, watching TV, using cell phone, listening to music with headphones
No homework or computer use
Cognitive "shut-down"
Use darkened, quiet room
2
Limited School Attendance (Half Days/Part-Time)
Maximum Accommodations
Able to tolerate up to 30 minutes mental extertion

 

Limit/partial class attendance; no PE
Periodic rest breaks away from class in a quiet area
Allow to lay head down at desk
Limit/modify academic classwork
No major/standardized testing
Provide extra help; peer note taking
"Clear desk" and listen
Extra time for quizzes in a quiet area
Extra time for assignments; modify assignments
Minimal or no homework
3
Full-Day Attendance (Limit Class Attendance)
Moderate Accommodations
Able to tolerate up to 45 minutes mental extertion
No more than 1 ImPACT Summary Composite Score
exceeding RCI
No PE
Limit class attendance in academically challenging classes
No major/standardized testing; modified testing
Rest periods in classroom as needed
Extra time for assignments; quizzes as needed
Limited homework, i.e., less than 30 minutes
4
Full Class Attendance
Minimal Accommodations
Able to tolerate up to 60 minutes mental extertion
*Graded Symptom Scale Score: <10
No PE
Increase return to normal class workload
Begin working on missed work/assignments
Moderate homework, i.e., less than 60 minutes
5
Full Academics
No Accommodations
*Graded Symptom Scale Score: 0
Resume normal homework assignments
Identify essential content and assignments to make up
Develop realistic timeline for completing assignments
Re-evaluate weekly until assignments are completed
When indicated by school's athletic trainer or a licensed health care provider, start Step 2, "Return to Play" progression
No PE until completion of "Return to Play" progression
*Graded Symptom Scale Score ranges shown are a general guide and are not intended as objective criteria for dilineating stages of recovery or indication for specific instructional modifications or academic accommodations. Graded Symptom Scale Score ranges are extremely subjective and vary dramatically by individual, and also dependent on the selected Grading Symptom Scale used to derive a symptom score.
REFERENCES:

Oregon Concussion Awareness and Management Program, Max’s Law: Concussion Management Implementation Guide for School Administrators. Center on Brain Injury Research & Training, Western Oregon University. http://www.ode.state.or.us/teachlearn/subjects/pe/ocampguide.pdf

Halstead ME, McAvoy K, Devore CD, Carl R, Lee M, Logan K, Council on Sports Medicine and Fitness, and Council on School Health. Returning to Learning Following Concussion. Am Acad Pediatrics, 132 (5) 948–957, Nov 2013. http://pediatrics.aappublications.org/content/132/5/948.full.pdf+html.

ImPACT Applications, Inc., September 2013. [Webinar] Almquist J, Connecting the Dots Between Clinical Assessment and Academic Accommodations.

Center for Disease Control, US Dept. of Health and Human Services, 2013. Heads Up to Schools: Know Your Concussion ABC’s. Returning to School After a Concussion: A Fact Sheet for School Professionals. http://www.cdc.gov/concussion/pdf/TBI_Returning_to_School-a.pdf.

The REAP Project. McAvoy K. REAP The Benefit of Good Concussion Management. Rocky Mountain Hospital for Children, Center for Concussion. http://issuu.com/healthone/docs/reap_oct21/1?e=1811185/5400960.

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