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Returning to Learning Following a Concussion

Mark Halstead, MD, FAAP

St. Louis Children’s Hospital

Cynthia Di Laura Devore, MD, FAAP

Pediatrician Specializing in School Health

Karen McAvoy, PsyD

Rocky Mountain Hospital for Children

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Disclaimers

Statements and opinions expressed are those of the authors and not necessarily those of the American Academy of Pediatrics.

 Mead Johnson sponsors programs such as this to give healthcare professionals access to scientific and educational information provided by experts. The presenters have complete and independent control over the planning and content of the presentation, and are not receiving any compensation from Mead Johnson for this presentation. The presenters’ comments and opinions are not necessarily those of Mead Johnson. In the event that the presentation contains statements about uses of drugs that are not within the drugs' approved indications, Mead Johnson does not promote the use of any drug for indications outside the FDA-approved product label.

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Objectives

 Discuss background and epidemiology of concussions.

 Understand common signs and symptoms of concussion.

 Describe the Return to Learning Team Concept.

 Develop strategies for returning to the classroom following a concussion.

 Understand how to assist the concussed student with prolonged symptoms.

 Discuss determining readiness to return to learn.

 Discuss classroom strategies to return to learn, especially related to specific signs and symptoms.

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Epidemiology: Boys Sports

Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958– 963; Castile L, Collins CL, McIlvain NM, et al. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010. Br J Sports Med. 2012;46(8):603–610; and Marar M, McIlvain NM, Fields SK, et al. Epidemiology of concussion among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(40):747–755

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Epidemiology: Girls Sports

Lincoln AE, Caswell SV, Almquist JL, et al. Trends in concussion incidence in high school sports: a prospective 11-year study. Am J Sports Med. 2011;39(5):958– 963; Castile L, Collins CL, McIlvain NM, et al. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010. Br J Sports Med. 2012;46(8):603–610; and Marar M, McIlvain NM, Fields SK, et al. Epidemiology of concussion among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(40):747–755

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Concussion Epidemiology

Marar M, McIlvain NM, Fields SK, et al. Epidemiology of concussion among United States high school athletes in 20 sports. Am J Sports Med. 2012;40(40):747–755

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Mechanism of Injury

Gessel LM, Fields SK, Collins CL, et al. Concussion among United States high school and collegiate athletes. J Athl Train. 2007;42(4):495–503

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Common Signs and Symptoms

Physical Emotional Headache Dizziness Sensitivity to light Sensitivity to noise Visual changes (blurry vision; double vision) Nausea/vomiting Fatigue

Cognitive Difficulty remembering Difficulty concentrating Feeling slowed down/foggy Difficulty with clear thinking

Irritability Sadness More emotional Nervous/anxious

Sleep Sleeping more than usual Sleeping less than usual Trouble falling asleep

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Common Symptoms

Meehan WP 3rd , d’Hemecourt P, Comstock RD, et al. High school concussion in the 2008-2009 academic year: mechanism, symptoms, and management. A J Sports Med. 2010;38(12):2405–2409; Castile L, Collins CL, McIlvain NM, et al. The epidemiology of new versus recurrent sports concussions among high school athletes, 2005-2010. Br J Sports Med. 2012;46(8):603–610

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Physical Symptoms



Headache

o Can distract from concentration o Can vary throughout days with various triggers 

Dizziness/Lightheadedness

o Can indicate vestibular system injury o Can be provoked with visual stimulus (video, rapid movements) o Standing or walking in crowded environment may be difficult

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Physical/Cognitive Symptoms

   Visual symptoms o Can affect ability to watch: videos, slide shows, smart boards, tablets, o o computers, artificial lighting Difficulty reading and copying Difficulty paying attention to visual tasks Noise sensitivity o Can affect ability to be in: lunchroom, noisy hallways, shop classes, music classes, organized sport practices Difficulty remembering/concentrating o Test taking o Difficulty recalling or applying previously learned material o Standardized test taking o Driver’s education classes

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Sleep Symptoms



Sleep Disturbances

o Excessive fatigue can hamper memory o Can cause tardiness or excessive absences o Sleeping in class o Excessive napping can further affect disrupted sleep cycle

FOR OFFICE USE ONLY

Name _______________ _____________________ TM DOB _____/_____/_____ DOS _____/_____/_____ Previous Symptom Score (if available) ________________

IMPORTANT :

Please have the

PATIENT

fill out based on what symptoms they have

Symptom Checklists

NONE MILD MODERATE SEVERE Headache “Pressure in Head” Neck Pain Nausea or Vomiting Dizziness Blurred Vision

0 0 0 0 0 0 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 3 4 4 4 4 4 4 5 5 5 5 5 5 6 6 6 6 6 6

Balance Problems Sensitive to Light Sensitive to Noise Feeling Slowed Down Feeling “in a fog” “Don’t feel right” Difficulty Concentrating Difficulty Remembering Fatigue or Low Energy Confusion Drowsiness Trouble Falling Asleep More Emotional Irritability Sadness Nervous or Anxious

For Doctor Halstead ’s Use Only

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 5 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6 6

10/2013

TSS __________

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The Return to Learning Team Concept



Medical team



Family team



School teams:

o academic team o physical activity team

Effect of Concussion on School Learning & Performance

Effect of School Learning & Performance on Concussion Recovery

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The Role of the Medical Team

 Educate the child or adolescent and family on the nature and typical course of concussion, and the importance of rest, cognitive and physical, during recovery.

 Designate an office staff member as the contact person who can serve as the liaison between the medical home, the family, and the school, and communicate concerns back to the pediatrician.

 Verify symptoms that might interfere with learning and communicate with the school, and reassess the student as indicated based on family and school feedback.

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The Role of the School Teams

 Allow a student to rest and return to learning at a pace consistent with recommendations from the medical home, based on verified signs and symptoms.

 Designate a staff member as the contact person who can serve as the liaison between the medical home, the family, and the school, and communicate concerns back to the pediatrician and parent.  Report back to family and pediatrician on how the child or adolescent is managing, and work as a team to advance, regress, or hold the student steady in his/her return efforts.

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The Role of the Family Team

 Enforce rest and reduce stimulation as prescribed by the pediatrician.

 Work with the school to develop a plan for return to learning and sign essential releases to allow communication between the school and the medical homes.

 Monitor the child for readiness to begin a return to learning process and keep the medical and school homes updated.

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Guidance for Determining Student Readiness to Return to Learning

Student tolerance of cognitive stimulation or concentration.

SYMPTOM ONSET <30-45 minutes

REST AT HOME

Encourage sleep Light mental activity Light reading or light TV Light interaction with family No driving, no employment, no malls, decreased screen time/social networks/video games/computer work.

SYMPTOM ONSET >30-45 minutes School Attendance ADJUSTMENTS AS NEEDED FOR SYMPTOM EXACERBATION 30-34 min. of instruction 15 min. rest period Additional instruction as tolerated Late start/early dismissal, planned/as needed rests, increase activity as tolerated, no extracurricular until back to full curricular program. For missed instruction consider class notes, easing assignments, reduced course load, etc.

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Tutoring Following Concussion

 Tutoring is almost never indicated: o In the early phases of recovery o In-home for concussion alone  Tutoring may be indicated for a student who cannot tolerate crowds, but can attend 30-40 min. Yet, the goal should be for the student to leave the home: o Work in the school library with teacher after hours o Avoid passing time in the halls o Avoid crowded areas, cafeterias, auditoriums, gymnasiums  Tutoring may be indicated for a student who cannot leave home for reasons other than concussion, such as a concussion associated with multiple severe injuries besides a concussion or recovering from surgery.

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Sample Six Step “Return to Learning” Model Based on Six Step “Return to Play” Model

 Step 1 Rest and recovery at home without any academics  Step 2 Light mental activity in quiet environment (30-45 min.)  Step 3 More sustained mental activity in more stimulating environments for longer periods and shorter breaks  Step 4 Increased mental activity in regular school setting with continued adjustments only as needed  Step 5 Full day in all academic classes with adjustments as needed  Step 6 Regular school attendance full time with no restrictions

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Strategies to Help in the School Setting based on Symptoms



Adjustments



Accommodations



Modifications

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Academic Adjustments



Can be implemented immediately



Are temporary, for up to usually 3 weeks or less



Are easily adjusted and changed based on need



Are done at building level by principal and teaching team



Can address all aspects of instruction except standardized testing



Involves General Education

Sign/Symptom Headache Potential Adjustments in School Setting

   Frequent breaks Identifying aggravators and reducing exposure to them Rests, planned or as needed, in nurse’s office or quiet area

Dizziness

  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

Light sensitivity

     Reduce exposure to computers, smart boards, videos Reduce brightness on the screens Allow the student to wear a hat or sunglasses in school Consider use of audio tapes of books Turn off fluorescent lights as needed

Noise sensitivity

   

Limit or avoid band, choir, or shop classes Avoid noisy gyms and organized sports practices/games Consideration of the use of ear plugs Give student early dismissal from class and extra time to get from class to class to avoid crowded hallways during pass time Difficulty with memory

     Avoid testing or completion of major projects during recovery when possible Provide extra time to complete non-standardized tests Postpone standardized testing (may require that a 504 Plan is in place) Consider one test per day during exam periods Consider the use of preprinted notes, note taker, scribe, or reader for oral test taking

Sleep problems

 

Allow for late start or shortened school day to catch up on sleep Allow rest breaks

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Summary

 Concussion impacts learning and the stress of learning can impact concussion recovery.

 A team approach combining point persons to optimize communication among the medical home, the school home, and the family home to create an individualized re-entry plan is vital.

 The medical team substantiates medical need and identifies signs and symptoms; the family team reinforces rest and determines/monitors readiness to return to learning; the school teams work with the medical home and family to make immediate temporary adjustments to ensure a successful re-entry.

 Creativity and flexibility by the school, based on symptom triggers, are key to an early and successful recovery and re-entry process.

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Prolonged Symptoms

Recovery From Concussion

100 90 80 70 60 50 40 30 20 10 0 Series1 1 2 3 4

Weeks Post Concussion

5 Collins M, Lovell MR, Iverson GL, et al. Examining concussion rates and return to play in high school football players wearing helmet technology: a three-year prospective cohort study. Neurosurgery. 2006;58(2):275–286

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Response to Intervention (RtI) or Multi-tier System of Support RtI: Instruction and Targeted Support for All Levels of Need Three Tiered Model of School Supports: Example of an Infrastructure Resource Inventory Academic Systems

Tier III: Comprehensive and Intensive Interventions – Few Students (Students who need individualized interventions) Tier II: Strategic Interventions – Some Students (Students who need more support in addition to the core curriculum) Tier I: Core Curriculum –

All Students

Behavioral Systems

Tier III: Intensive Interventions – Few Students (Students who need individualized interventions) Tier II: Targeted Group Interventions – Some Students (Students who need more support in addition to the core curriculum) Tier I: Universal Inventions –

All Students, all settings

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RtI/or Multi-tier System of Support as Applied to Concussion RtI: Instruction and Targeted Support for All Levels of Need Three Tiered Model of School Supports: Example of an Infrastructure Resource Inventory

Tier III: Special Education/IDEA permanent brain damage =

Academic Modification

of curriculum, specialized instruction or placement Tier II: Longer-term plan due to prolonged effects of concussion. May be a 504 Plan =

Academic Accommodations.

Still responsible for curriculum but will provide supports to environment, more targeted interventions for a longer period of time Tier I: Typical recovery from concussion =

Academic Adjustments

Universal interventions, applied in general education, fast, fluid, flexible, put in place immediately and lifted regularly as symptoms improve daily Tier III: Intensive Interventions – Few Students (Students who need individualized interventions) Tier II: Targeted Group Interventions – Some Students (Students who need more support in addition to the core curriculum) Tier I: Universal Inventions –

All Students, all settings

Interventions:

Adjustments – Informal, flexible day to-day interventions. Can be applied immediately and lifted easily when no longer needed.

Provided in:

General Education classroom.

Accommodations – More formal process for longer interventions; often called a 504 Plan. Requires a meeting to enter and exit. Modifications – Very formal process to document a chronic and permanent disability of brain injury; referred to as Special Education or Individuals with Disabilities Education Act (IDEA). Disability makes it so that student cannot benefit from General Education alone.

Student still required to progress through General Education curriculum. General Education classroom; occasional extra support/targeted interventions outside of General Education.

Student still required to progress through General Education curriculum with accommodations to the environment (i.e., extra time, large print, rest).

Primary services provided in Special Education classroom; student in General Education classroom as much as possible.

Affects:

80% to 90% of students with a concussion for the typical 3 week recovery.

Apply for days to weeks.

5% to 15% of students with prolonged symptoms from a concussion.

Apply for weeks to months. 1% to 5% of students with permanent brain damage; brain damage sustained as a concussion.

Allows for modification of the General Education curriculum. Often requires specialized instruction and specialized placement.

Apply for months to years.

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Maximize Recovery with Academic Adjustments 80% to 90% Tips:

  Do not be too prescriptive on these initial adjustments.

Allow teachers to apply them as generously as they please and allow them to adjust depending upon student’s:  Type of symptoms  Type of content material  Type of teaching style Areas of strengths and weaknesses Time of day of class

80% to 90%

Allow teachers to apply and lift interventions as they see fit. Symptoms should start resolving from week 1 to week 2 to week 3. Academic adjustments should be lifted over the 3 weeks and the student with the typical concussion should be almost back to 100% pre-concussion learning level by 3 weeks.

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Special Education/IDEA/IEP 1% to 5%

Tips:

 Permanent brain damage secondary to a concussion.

 Proven over a significant amount of time that skills will not be returning.

 MD can be helpful in documenting the brain injury but a medical diagnosis does not automatically = an individualized education plan (IEP).

 School gets to determine if, due to the disability, student can no longer “benefit from General Education alone.” School is capable of doing the assessment internally.

 If found to be appropriate for a Special Education/IDEA/IEP, student now will need specialized instruction, specialized placement, and/or modified curriculum.

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The Tricky “In-Between” 5% to 15%

Tips:

 Prolonged symptoms but still hoping to get close to, if not, full recovery.

 Getting resolution with time but need more time and more intervention.

 MD can be helpful in documenting the protracted recovery of concussion but a diagnosis does not automatically = a 504 Plan.

 School gets to determine if the “physical impairment substantially limits one or more major life activities” (in this case: learning). School is capable of doing the assessment internally.

 If found to be appropriate for a 504 Plan, student will still be responsible for the General Education curriculum but can receive accommodations to the environment to support learning.

 A 504 Plan “ levels ” the playing field.

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When 504 Plans/Health Plans Can Be Very Helpful…

When you are 4+ weeks into recovery, progress is promising, but slow, and you know recovery will take: more time and/or more treatment (i.e., vestibular and/or physical therapy). Concussed student has been placed on medication for prolonged symptoms and you know you cannot discontinue prescription for a number of months. A 504 Plan in this case will allow schools to provide specific accommodations longer while awaiting maximum effectiveness of the prescription.

Both of the above uses of a 504 Plan help to “buy” more time for recovery and decrease the stress of the daily questions, “Are you better today? Can you take this test today?” It protects the student and the school.

TIP: A 504 Plan should be specific to the problem area MD is treating (i.e., “headaches secondary to concussion,” “mental fatigue secondary to concussion”) and interventions should be picked thoughtfully and prescriptively.

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Symptom Wheel

• • • • •

Adjustments

“strategic rest” scheduled breaks Sunglasses Quiet room environment More frequent breaks in classroom/clinic Remove from physical education, recess, and dance classes without penalty

P HYSICAL

headache/nausea dizziness balance problems blurred vision/ photophobia noise sensitivity neck pain

E MOTIONAL C OGNITIVE E S NERGY LEEP /

• 504 Plan for “headaches secondary to a concussion:” Interventions: allowed to wear sunglasses at school visit nurse for pain medications and rest when experiencing headache

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Symptom Wheel

P HYSICAL C OGNITIVE

concentration remembering mentally foggy slowed processing • 504 Plan for “slowed processing speed secondary to a

E MOTIONAL ENERGY/SLEEP

Interventions: extra time on tests and assignments reduce number of math problems (but not social study problems) by 50% and/or until mastery demonstrated allow for teacher/buddy notes • • • • • • • •

Adjustments

Workload reduction in classroom and homework Adjust “due” dates Allow student to “audit” class work Exempt/postpone large tests/projects Alternative testing Allow for “buddy notes” Allow for technology Do not penalize for class work/homework not completed during recovery 37 McAvoy, 2011

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When 504 Plans are Not Helpful…

When you are 4 to 6+ weeks into recovery and you know you are almost ready to turn the corner on the concussion—if the school is willing, stay the course and do not take the time to call together a meeting for a 504 Plan. Let the student clear.

Excessive absences or truancy—a 504 Plan is not to be used to allow concussed students to be out of school. In fact, developing a 504 Plan requires school and MD to be even more accountable and thoughtful about educating a student while MD is actively intervening on the medical reasons for protracted recovery. If a student is excessively truant, consider underlying co-existing reasons (i.e., school avoidance, anxiety).

NOTE: Home tutoring should be used sparingly, only short term, and only until the MD can figure out why these symptoms are so severe, can find the right treatment, and can get the student back to school. It often cannot be initiated until student has been out of school already for 3+ weeks and it challenges Least Restrictive Environment placement in school, so it should be used only in the most extreme and complicated cases.

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Return to Learning Before Returning to Play (RTP)

A student with permanent brain damage, secondary to a concussion, technically never returns 100% to pre-concussion state, technically never can get to Step 1 of graduated RTP, and therefore cannot RTP.

Depending upon the burden of the prolonged symptoms and the effectiveness of the treatments and/or medications and the possible need for a 504 Plan, getting to Step 1 of RTP steps is case by case and therefore, clearance is case by case. However, technically a student on a 504 Plan is not 100% symptom-free, so technically a student cannot start the RTP steps if a 504 Plan is still needed.

A student who returns to learning within the typical amount of time with no complications will be at Step 1 of the graduated RTP steps in a reasonable amount of time and RTP seems justifiable.

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Conclusions

1. Concussed students will need academic adjustments in school.

2. Given that most concussions resolve in 3 weeks, General Education interventions are recommended without formal plans such as a 504 Plan or IEP.

3. Students with symptoms lasting 3 to 4 weeks may benefit from a more detailed assessment and consideration of a 504 Plan, but likely not an IEP. 4. A team approach consisting of a medical team, school teams, and family team is ideal.

5. Students should be performing at their academic “baseline” before being returned to sports.

6. Education of all individuals involved with students who sustain a concussion is necessary to provide adequate academic adjustments, accommodations, and modifications.

7. Additional research is necessary to strengthen evidence-based recommendations for appropriate academic adjustments for students following a concussion.

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Looking for additional school health or sports medicine guidance?

Council on School Health

The Council on School Health (COSH) defines school health as an integration of wellness, safety, growth, learning, and development in the lives of school aged children and adolescents within the context of their school, and with the coordinated alliance of the family and the medical home. For more information visit www2.aap.org/sections/schoolhealth/

Council on Sports Medicine and Fitness

The Council on Sports Medicine and Fitness (COSMF) supports and encourages optimal and safe physical activity in the pediatric population and ensures that pediatric providers are prepared to provide the highest level of sports medicine guidance and care for their patients. For more information visit www.aap.org/COSMF

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