CLINICAL REPORT

Returning to Learning Following a Concussion

abstractFollowing a concussion, it is common for children and adolescents toexperience difficulties in the school setting. Cognitive difficulties, suchas learning new tasks or remembering previously learned material,may pose challenges in the classroom. The school environment may alsoincrease symptoms with exposure to bright lights and screens or noisycafeterias and hallways. Unfortunately, because most children and ado-lescents look physically normal after a concussion, school officials oftenfail to recognize the need for academic or environmental adjustments.Appropriate guidance and recommendations from the pediatricianmay ease the transition back to the school environment and facilitatethe recovery of the child or adolescent. This report serves to providea better understanding of possible factors that may contribute to diffi-culties in a school environment after a concussion and serves as a frame-work for the medical home, the educational home, and the family home toguide the student to a successful and safe return to learning. Pediatrics2013;132:948–957

DEFINITIONS

� Individualized education plan (IEP): a formalized educational planprotected under the Individuals with Disabilities Education Act(IDEA; Pub L No. 101-476, 1990), known commonly as special edu-cation, that provides for classification or coding of a student under1 of 13 federally designated categories and allowances for modi-fication of regular education without penalty to the student.

� 504 plan: under Section 504 of the Rehabilitation Act (Pub L No.93-112, 1973) and the Americans with Disabilities Act (Pub L No.101-336, 1990), provides for a student who is not eligible for specialeducation under an IEP but who requires accommodations in reg-ular education on the basis of bona fide medical need, as docu-mented by a physician and validation by the educational home.

� Individualized health care plan: a written document created bya school nurse on the basis of information provided by the stu-dent’s pediatrician to document specific health care needs in theschool setting with a plan for addressing each documented need.

� Family Educational Rights and Privacy Act (FERPA): a federal lawestablished in 1974 (Pub L No. 93-380) that protects the privacy ofstudents’ “education records,” including school health records,and applies to educational agencies and institutions that receivefunds under any program administered by the US Department of

Mark E. Halstead, MD, FAAP, Karen McAvoy, PsyD, Cynthia D.Devore, MD, FAAP, Rebecca Carl, MD, FAAP, Michael Lee,MD, FAAP, Kelsey Logan, MD, FAAP, Council on SportsMedicine and Fitness, and Council on School Health

KEY WORDShead injury, mild traumatic brain injury, pediatrics, return toschool, academics, return to learn, cognitive deficits

ABBREVIATIONSAT—certified athletic trainerFERPA—Family Educational Rights and Privacy ActHIPAA—Health Insurance Portability and Accountability ActIEP—individualized education planIDEA—Individuals with Disabilities Education ActRTL—return to learn

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors. All authorshave filed conflict of interest statements with the AmericanAcademy of Pediatrics. Any conflicts have been resolved througha process approved by the Board of Directors. The AmericanAcademy of Pediatrics has neither solicited nor accepted anycommercial involvement in the development of the content ofthis publication.

The guidance in this report does not indicate an exclusivecourse of treatment or serve as a standard of medical care.Variations, taking into account individual circumstances, may beappropriate.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-2867

doi:10.1542/peds.2013-2867

All clinical reports from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmed,revised, or retired at or before that time.

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Copyright © 2013 by the American Academy of Pediatrics

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Education. Schools require FERPApermission from parents to releaseany information to any entity, in-cluding physicians. FERPA does notcover requirements of the Health In-surance Portability and Accountabil-ity Act (HIPAA). Other details can befound at: http://www.ed.gov/policy/gen/guid/fpco/index.html.

� Health Insurance Portability and Ac-countability Act (HIPAA): the PrivacyRule of HIPAA (Pub L No. 104-191,1996) requires “covered entities,” in-cluding physicians, to protect indi-viduals’ health records and otheridentifiable health information withappropriate safeguards to protectprivacy and sets limits and condi-tions on the uses and disclosuresthat may be made of such informa-tion without patient authorization.HIPAA covers FERPA requirements.More information is available athttp://www.hhs.gov/ocr/privacy.

� Child Find: Child Find is a continuousprocess of public awareness activi-ties, screening, and evaluation de-signed to locate, identify, and referas early as possible all young chil-dren with disabilities and theirfamilies who are in need of EarlyIntervention Program (Part C) orPreschool Special Education (PartB/619) services of the IDEA.

INTRODUCTION

Much attention has been paid to con-cussions in children and adolescents,particularly concussions resulting fromsports. The majority of the focus onconcussions has been centered on di-agnosis, education of key stakeholdersregarding the problem, and the timingof safe return to play (that is, to sportsand other physical activity). Unfortu-nately, little attention has been given toacademics and learning and how aconcussion may affect the young studentlearner. Developing appropriate guidanceand evidence-based recommendations

for a “return to learn” (RTL) for a studentfollowing a concussion is a challenge,given the limited research that exists inthis area of concussion and its man-agement. Because of this shortage ofresearch, the guidance provided in thisclinical report is based primarily on ex-pert opinion and adapted from a pro-gram developed in Colorado to addressthe issue of RTL.1 Data are currently in-sufficient to advocate the ideal way tomanage the RTL in the pediatric pop-ulation.

Pediatricians report that inadequatetraining on concussion management isamong the most significant barriers toeffectively counseling patients on re-turning to school following a concus-sion.2 There are many publishedstatements that discuss the importanceof “cognitive rest” following a concus-sion.3–5 Cognitive rest refers to avoidingpotential cognitive stressors, such astexting, video games, TV exposure, andschoolwork, as examples. However, todate, there is no research documentingthe benefits or harm of these methodsin either the prolongation of symptomsor the ultimate outcome for the studentfollowing a concussion. Given the dis-ruptive nature that concussion symp-toms may pose for the student and hisor her family, adding additional re-strictions that may not be needed hasthe potential to create further emo-tional stress during the recovery. Thiscalls for an individualized approachfor the student when a pediatrician ismaking recommendations for cognitiverest and the student’s RTL in the schoolsetting.

BACKGROUND

With an estimated 1.7 million traumaticbrain injuries occurring annually, manyof them concussions, the need forspecific recommendations for return-ing a student to learning after concus-sion is necessary.6 Given that studentstypically appear well physically after

a concussion, it may be difficult foreducators, school administrators, andpeers of the student to fully understandthe extent of deficits experienced bya student with a concussion. This lack ofoutward physical appearance of illnessmay also make it difficult for schoolofficials to accept the need for adjust-ments for a student with a concussion.

Cognitive difficulties following a concus-sion have long been recognized andcan clearly affect a student’s learningcapabilities. With recent increased atten-tion to concussions, more focus has beenplaced on appropriate management forthis specific injury. Neurocognitive test-ing, particularly the commercially avail-able computerized versions, and its useafter concussion has become morewidespread, but the focus has beenprimarily on sports-related concus-sions. Although these neurocognitivetests may be helpful as a tool inassessing a student after a concussion,they have not been applied systemati-cally to determine when and howa student is ready to take on the typicalcognitive demands in a school setting.

Although a concussion can have obvi-ous direct effects on learning, there isalso increasing evidence that using aconcussed brain to learn may worsenconcussion symptoms and perhapseven prolong recovery.7,8 Increasingcognitive activities are hypothesizedto add additional stress to an energy-deprived brain, which may worsensymptoms. The goal during concus-sion recovery is to avoid overexertingthe brain to the level of worsening orreproducing symptoms. Determiningthe appropriate balance between howmuch cognitive exertion and rest isneeded is the hallmark of the man-agement plan during cognitive recovery.

There is insufficient research on therole of cognitive rest, although recentresearch suggests benefit to the con-cept of cognitive rest both early andlate in the recovery of the student.9

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SIGNS AND SYMPTOMS OFCONCUSSION AFFECTINGSTUDENTS

Many aspects of a concussion canaffect the student in the classroom.The common signs and symptoms thestudent may experience can be phys-ical, cognitive, emotional, or related tosleep. Fortunately, research has dem-onstrated that recovery for the school-age student occurs usually within 3weeks from the injury, but schooladjustments during this recovery pe-riod may be necessary.10

When evaluating the student, recognizingthe common signs and symptoms ofa concussion and how theymay affect thestudent in the school setting is important(Table 1). A thorough understanding ofpotential problems the student can en-counter will help the pediatrician makeappropriate recommendations to theschool, the student, and the student’sfamily. Allowing adequate cognitive restmay help minimize a worsening ofsymptoms and potentially facilitate aquicker recovery without significant dis-ruption to the student’s life.

Use of symptom checklists may helpnot only in evaluating what symptomsthe student may be experiencing butalso in rating them in severity (Figs 1and 2). These checklists can also beused serially to follow the studentthrough his or her recovery and identifyareas that may need more targetedinterventions.11 Because the diagnosis ofconcussion is largely symptom driven, itis important not only to recognize butalso to inquire further about the specificnature of the symptoms reported by thestudent or observed by the parent be-cause many of the symptoms reportedafter a concussion may not be unique toa concussion. For example, some stu-dents may have preexisting depression,chronic daily or intermittent headaches,learning disabilities, or attention-deficit/hyperactivity disorder, which can af-fect reporting on a symptom checklist.

Careful history taking to account forany possible preinjury conditions isuseful in assessing the student withconcussion, especially one with pro-tracted postconcussive symptoms. Thepediatrician should account for thesepreexisting conditions and continue tomanage the concussion and as well asthe preexisting problems concurrently.It is also worthwhile to discuss otherpotential stressors that may affectsymptom reporting, such as family orrelationship problems, pressures fromcoaches and teammates if the child isinvolved in organized sports, and the re-striction from participation in important

upcoming life events. Symptom check-lists and their scores may help in de-termining what symptoms may need tobe addressed when returning to theschool environment but should not bethe sole determining factor in decidingwhen to return a child to school aftera concussion.

THE RETURN TO LEARNING TEAM

A student returning to school after aconcussion may benefit from a multi-disciplinary team to maximize his orher recovery (Table 2).1 Because statelaws differ, the accessibility for some

TABLE 1 Signs and Symptoms of a Concussion and the Potential Problems They May Pose to theStudent

Sign/Symptom Potential Implications in School

Headache Most common symptom reported in concussionsCan distract the student from concentrationCan vary throughout the day and may be triggered by variousexposures, such as fluorescent lighting, loud noises, and focusingon tasks

Dizziness/lightheadedness May be an indication of injury to vestibular systemMay make standing quickly or walking in crowded environmentchallenging

Often provoked by visual stimulus (rapid movements, videos, etc)Visual symptoms: light sensitivity,double vision, blurry vision

Troubles with various aspects of the school building

Slide presentationsMoviesSmart boardsComputersHandheld computers (tablets)Artificial lighting

Difficulty reading and copyingDifficulty paying attention to visual tasks

Noise sensitivity Troubles with various aspects of the school buildingLunchroomShop classesMusic classes (band/choir)Physical education classesHallwaysOrganized sports practices

Difficulty concentrating orremembering

Challenges learning new tasks and comprehending new materials

Difficulty with recalling and applying previously learned materialLack of focus in the classroomTroubles with test takingTroubles with standardized testingReduced ability to take drivers education classes safely

Sleep disturbances Excessive fatigue can hamper memory for new or past learning orability to attend and focus

Insufficient sleep can lead to tardiness or excessive absencesDifficulty getting to sleep or frequent waking at night may lead tosleeping in class

Excessive napping due to fatigue may lead to further disruptions ofthe sleep cycle

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students to a school physician or aschool nurse may be less likely in somecommunities. It remains essential thatall schools recognize the importance ofteam management for a student afterconcussion and ensure that all stu-dents recovering from concussion haveassigned staff who will be responsiblefor smooth reentry to school. Yet in theideal situation, there is a school phy-sician in every district and a schoolnurse in every school, so that a medicalteam in the educational home canreadily work with the student’s medicalhome toward a child or adolescent’soptimal benefit and outcome.12,13

Even though a student may be havingsymptoms, ultimately, the goal is to keepdisruptions to the student’s life to aminimum and to return the recoveringstudent to school as soon as possible.The challenge of the multidisciplinaryteam is to balance the need for thestudent to be at school with the ap-propriate adjustments for the cognitivedemands at school that have the po-tential for increasing symptoms. Toreach the right balance at home andschool, the multidisciplinary teamsshould be well versed in their roles andresponsibilities in concussion manage-ment and keep communication openamong all parties regarding decisionsto progress, regress, or hold steadyduring the RTL process.

After a concussion, the student alreadyhas individuals in place for each of theteams described (Table 2). Ideally, at least1 person from each team is involved inthe concussion management and com-municating with each other to help fa-cilitate the recovery. The pediatriciandoes not need to create the teams orroles, but it will help to understand whatroles and responsibilities each team hasin the recovery of the student.

The role and responsibility of the familyteam is to enforce rest and to reducestimulation to the student during recov-ery. In the early phases of a concussion,

FIGURE 1Example postconcussion symptom score checklist (recommended for seventh grade and up).5 Use ofthe postconcussion symptom scale: the student should complete the form, on his or her own, bycircling a subjective value for each symptom. This form can be used with each encounter to trackprogress toward symptom resolution. Many students may have some of these reported symptoms ata baseline, such as concentration difficulties in the patient with attention-deficit disorder or sadnessin a student with underlying depression. This must be taken into consideration when interpretingthe score. Students do not need a total score of 0 to return to play if they had symptoms before theirconcussion. This scale has not been validated to determine concussion severity.

FIGURE 2Example of postconcussion symptom score checklist (recommended for kindergarten to sixthgrade).5

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symptoms may be so severe that theymay prevent the student from attendingschool or even accepting home tutor-ing. However, as symptoms becometolerable, short-lived, and/or amenableto rest and intervention, the studentmay return to school, often with the useof supplemental academic adjustments.Therefore, it is the parent who will ul-timately make the decision when thestudent should return to school. It is notunusual for a student to be extremelysymptomatic in the doctor’s office ini-tially but minimally symptomatic athome within several days. Some guid-ance to help decision making for returnto school can be found in Table 3.

The role and responsibility of the med-ical team is to evaluate the concussion,assess for a more serious structural orneurologic injury, and prescribe physi-cal and cognitive rest, as appropriate,until symptoms improve. As recoverycontinues, the medical team shouldgather data from the family and fromthe school teams to aid in the decision ofwhen to start to allow safe progressionback to increasing physical activity.

Two school teams are involved in therecovery process for the student witha concussion, the school physical ac-tivity team and the school academicteam. The roles and responsibilitiesof the 2 school teams are extensiveand varied. In the early stages of the

concussion, the primary goal of theschool physical activity team is tosafeguard the student from any furtherpotential injury to the brain. If a con-cussion has been suspected, it is rec-ommended that the student be removedfrom physical activity and be evaluatedby his or her pediatrician or other ap-propriate health care professionals forfurther diagnosis and management be-fore returning to physical activity. Pe-diatricians should counsel patients onthe current recommended return toactivity progressions, as outlined in theclinical report from the American Acad-emy of Pediatrics titled “Sport-RelatedConcussion in Children and Adolescents,”which may be applied to both athletesand nonathletes.3

Similarly, in the early phases of a con-cussion, the school academic teammust coordinate the return of the stu-dent to cognitive exertion and help tofacilitate the appropriate level of aca-demic adjustments necessary to reduceor eliminate symptoms. Whether com-munication occurs directly with a singleteacher or is coordinated across allteachers via the designated case man-ager, such as the school nurse, coun-selor, or school psychologist, it isessential for all adults working with thestudent to understand the effects ofa concussion on learning and how bestto reduce cognitive demands during this

period of recovery. The parent is en-couraged to return the student to school,even if the day is shortened, when thestudent can tolerate cognitive activity orstimulation for approximately 30 to 45minutes. This arbitrary cutoff is based onthe observation that a good amount oflearning takes place in 30- to 45-minuteincrements. High schools with 7 to 8consecutive classes often schedule peri-ods at 30- to 45-minute intervals. A stu-dent with a concussion can benefit from30minutes of instruction and a 15-minute“rest period” before changing classes.High schools on a “block schedule” usu-ally run 90-minute blocks (two 45-minuteperiods), which may require allowancesfor a planned rest midway through theblock. The concussed student maymaximize learning in 30- to 45-minuteincrements before needing to take arest (Table 3). Missing instruction, how-ever, may necessitate the need for theprovision of class notes, supplementaltutoring, or an easing of assignments orcourse expectations.

When the student returns to school,observing which classes exacerbate

TABLE 2 Multidisciplinary Team to Facilitate “Return to Learning”1

Team Members of the Team

Family team Student, parents, guardians, grandparents, peers, teammates, andfamily friends

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

School academic team Teacher, school counselor, school psychologist, social worker, schoolnurse, school administrator, school physician

School physical activity team School nurse, athletic trainer, coach, physical education teacher,playground supervisor, school physician

All members listed for a team do not need to be involved for successful concussion management. An individual, such asan emergency department physician, may only be involved in the initial assessment and suggestion for initiatingacademic adjustments. Some members may serve roles on various teams. Some schools may have access to only certainindividuals suggested for a team. This list is meant to serve as a framework to help pediatricians and others involved withconcussion management, possible roles they can serve for a student with a concussion.

TABLE 3 Sample Approach for Determininga Students’ Readiness to Return toLearning Following a Concussion17

If a student/athlete experiences symptoms enoughto affect his or her ability to concentrate ortolerate stimulation for even up to 30 minutes,the student should likely remain at home. Thestudent may consider light mental activities,such as watching TV, light reading, andinteraction with the family, until they provokesymptoms. Computer use, texting, and videogames should remain at a minimum.

When the student/athlete is able to toleratesymptoms comfortably for up to 30 to 45minutes, the parent may consider returninghim or her back to learning, either throughhome tutoring or in-school instruction withprogramming adjustment as needed. However,it is the parent who should communicate withthe school about the concussion and signa release of information for school personnel tocoordinate adjustments that may be needed asrecommended by the primary care provider.The level of adjustments are decidedcollectively by the parent, school, and primarycare provider based on severity, type, andduration of symptoms present.

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symptoms will allow for further ad-justments to be made to help reducesymptom provocation. Students may beable to tolerate some classes betterthan others, and consideration shouldbe given for reduced exposure for thoseclasses that the student cannot tolerateas well by substituting a study hallperiod, allowing for rest periods, ormaking adjustments to class schedules.

As the concussion symptoms improve,the school academic team and the familyteam should feel comfortable increasingmental and social activities, as toleratedby the student, and involving the med-ical team only as needed, apart frompreplanned follow-up visits. This maytranslate into parents allowing theirchild to attend a social gathering, watcha game, or return to driving. At school,this should translate into a teacher re-quiring more work from a student whois obviously feeling better and able totolerate longer periods of time of mentalexertion without provoking symptoms.

Pediatricians should encourage teachersto pick and choose the academic ad-justments most amenable to their classteaching style and content and mostappropriate for the phase of recovery ofthe concussion on the basis of a child’stolerance. Teachers and those on theschool academic team should reassessprogress at weekly intervals to deter-mine the effectiveness and continuedneed of adjustments. Direct communi-cation and attention to symptoms withthe student is helpful, because the stu-dent may not be willing to mentionproblems specifically to the teacher.Communication with a student shouldbe conducted in a private setting, be-cause many students prefer not to besingled out or draw additional attentionto themselves following the injury. Youn-ger students may be apprehensive ornot know how to effectively expresstheir academic struggles. High-achievingstudents may also be unwilling to “givein” to adjustments that are offered.

STRATEGIES TO RETURN TO LEARNIN THE CLASSROOM

Returning a student to the classroomwhile symptomatic from a concussionrequires an individualized approach.Most students will likely return to theclassroom while symptomatic fromtheir concussion. Each concussion isunique and may encompass a differentconstellation and severity of symp-toms. Concussion symptoms may varyfrom student to student and even fromconcussion to concussion in the sameindividual who may sustain more thanone concussion. Therefore, a “cookie-cutter” approach to managing a con-cussion and a return to the classroomcannot be applied. However, most ofthe difficulties that arise in studentscan be handled with similar adjust-ments, depending on the signs orsymptoms they are experiencing.

In the first few weeks after a concus-sion, most interventions can be made inthe general education classroom, by thegeneral education teacher, with mini-mal support and check-ins with theschool physician, school nurse, schoolcounselor, school psychologist, schoolsocial worker, or certified athletictrainer (AT).14,15 Parents should be en-couraged to follow up with the schooland student to assess whether aca-demic adjustments are occurring tominimize worsening of students’ symp-toms during their early recovery.

Physicians should learn educationalterminology to assist them in beingprecise in what they are requesting ofschools. The term “academic adjust-ment” is used intentionally to refer tononformalized adjustments made tothe student’s environment during thetypical 1- to 3-week recovery periodthat do not jeopardize the curriculumor require alterations in standardizedtesting. The term “academic accom-modations” is used to address longer-term needs, beyond 3 weeks, which mayinclude standardized testing arrangement,

extra time on work, changes in classschedule, for example, and access tothe grade-level curriculum but stillwithin the context of regular educationand may be formalized in a 504 plan.The term “academic modification” isused when considering more prolongedand more permanent changes to aneducational plan, necessitating specialeducation with needs specified in anIEP. Teachers’ understanding and put-ting a few reasonable adjustments inplace in the early stages of the concus-sion will often help bring the studentthrough recovery in the typical, expectedtimeframe of 1 to 3 weeks. The typeof academic adjustments put in placeshould depend on the severity of thesymptoms, the type of symptom, spe-cific teaching styles used by a teacherin the classroom, and pattern of thesymptoms (Table 4).

Concussion education can be con-ducted by the pediatrician via directcommunication with school personnelon a case-by-case basis to facilitatebetter understanding among appro-priate school personnel during the RTLprocess; restrictions and adjustmentsshould be specifically listed on a schoolnote at each visit and during the in-terim, if needed. Unfortunately, simplyrequesting this in written form does notguarantee the school can or will com-ply. It would be helpful for the pedia-trician if the school could identify a“point person” or case manager tocontact at the school and likewise forthe school to be given a “point person”in the pediatrician’s office who willcommunicate with each other duringthe RTL process. FERPA permission isneeded by educational agencies, andHIPAA permission is required by med-ical personnel; therefore, a signed pa-rent permission on a document thatsatisfies both is required for commu-nication among team members. Theschool point person is often a memberof the school academic team. The

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medical home point person is some-one with enough knowledge of thesituation and of the child to commu-nicate concerns back to the pediatri-cian. Parents should also be involvedwith this communication.

The team approach between the med-ical home and a school staff member ishelpful in assisting the school withproblems it encounters in the processand identifying solutions to theseproblems. A team approach also canreduce the likelihood of a pediatrician’soffice from receiving frequent phonecalls from many individuals about thesame situation. For many schools, thepoint person would be a guidancecounselor, school psychologist, schoolphysician, or school nurse. In schools inwhich a AT is present, the AT can helpreinforce communication of any schoolor sports restrictions to safeguard

against the student-athlete beginninga return to play protocol but still havingacademic adjustments.15 For this rea-son, communication with the AT by thetreating physician or a representativeof the school who has been communi-cating with the physician is also en-couraged.16 In some circumstances,the AT may be limited to support onlythe students in organized sports for theschool rather than the student body asa whole. It would be helpful to the pe-diatrician to understand how ATs canassist the pediatrician with the man-agement of their patients.

Encouraging parents to communicatewith the school, especially the designatedcase manager, about how recommen-ded adjustments are being applied canbe helpful. Pediatricians should alsoencourage parents to communicate withtheir child to make sure any adjust-

ments that are being offered are alsobeing used, as needed, and are helping.

PROLONGED SYMPTOMS

Fortunately, most students with a con-cussion will recover within the first 3weeks from their injury.10 For studentswith symptoms lasting longer than 3weeks, further medical managementconsiderations and accommodations,rather than academic adjustments, maybe needed. Schools currently have inplace a system for accommodations(504 plan) for students expected to havetemporary interference with learning ormodifications (IEP) for students with aclassifiable chronic condition. However,applying these systems to concussions,in some schools, may be a newer con-cept. Although healing may be considered“protracted” with some concussions,the expectation is still for a full recoverythat no longer would require academicadjustments, accommodations, or modi-fications. Referral to a concussion spe-cialist (licensed physician, such as apediatrician, neurologist, primary caresports medicine specialist, or neuro-surgeon with expanded knowledge andexperience in pediatric concussion ma-nagement) should also be considered, ifnot already initiated, for the studentwith prolonged symptoms.

Because laws, regulations, policies, andpractices vary among states, districts,and schools, it is important that thepediatrician be familiar with the level offlexibility and creativity that a particularschool will provide or permit. Differ-ences also exist among long-term mod-ifications, midterm accommodations, andshort-term adjustments. Pediatriciansshould understand that the IDEA pro-vides for longer-term accommodations.For example, there are provisions forschool-based problem-solving teams todetermine the appropriateness of anIEP for a child in need of long-termmodifications through special educa-tion on the basis of a given classification.

TABLE 4 Signs and Symptoms of a Concussion and the Strategies to Help in the School Setting

Sign/Symptom Potential Adjustments in School Setting

Headache Frequent breaksIdentifying aggravators and reducing exposure to themRests, planned or as needed, in nurses office or quiet area

Dizziness Allow student to put head down if symptoms worsenGive student early dismissal from class and extra time to get fromclass to class to avoid crowded hallways

Visual symptoms: light sensitivity,double vision, blurry vision

Reduce exposure to computers, smart boards, videos

Reduce brightness on the screensAllow the student to wear a hat or sunglasses in schoolConsider use of audiotapes of booksTurn off fluorescent lights as neededSeat student closer to the center of classroom activities (blurryvision)

Cover 1 eye with patch/tape 1 lens if glasses are worn (doublevision)

Noise sensitivity Allow the student to have lunch in quiet area with a classmateLimit or avoid band, choir, or shop classesAvoid noisy gyms and organized sports practices/gamesConsideration of the use of earplugsGive student early dismissal from class and extra time to get fromclass to class to avoid crowded hallways during pass time

Difficulty concentrating orremembering

Avoid testing or completion of major projects during recovery whenpossible

Provide extra time to complete nonstandardized testsPostpone standardized testing (may require that 504 plan is inplace)

Consider 1 test per day during exam periodsConsider the use of preprinted notes, notetaker, scribe, or readerfor oral test taking

Sleep disturbances Allow for late start or shortened school day to catch up on sleepAllow rest breaks

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In addition, a 504 plan is availablethrough the Rehabilitation Act of 1973and Americans with Disabilities Act of1990 for a child who needs longer-termacademic accommodations in regulareducation but does not qualify for spe-cial education through 1 of the 13classifications available via an IEP. Mostadjustments can and should be shortterm and through the child’s educationalteam, with guidance from the medicalhome and approval by the principal andfamily team. The key to this process isthat the pediatrician provides the schoolwith medical documentation based onpersisting signs and symptoms thatmight significantly limit a child’s abilityto access full instruction. It is alsohelpful for the pediatrician to realizethat, often, schools will not allow achild to participate in extracurricularactivities until he or she is fully par-ticipating in curricular activities.

Early in the recovery, a student mayneed simple academic adjustments inthe classroom. Students who do notrespond in the first few months mayneed a more targeted level of in-tervention. At this level, school teamsmay need to brainstorm and problemsolve what other interventions may behelpful and decide whether more for-malized assessments need to occur.Often, the family team is a critical part ofthe problem-solving process, as is themedical team. All 3 teams must be ac-tively involved in managing the con-cussion on behalf of the recoveringstudent. At this level, some of theinterventions can no longer be easilyapplied in the general education class-room without formal intervention. Forexample, students may require someamount of pullout from the regularclassroom for a small-group interven-tion, tutoring, or 1-on-1 instruction.Customized plans at this point may bemore formalized into an IndividualizedHealth Plan, a learning plan, or a 504plan. Interventions at this level are

usually accommodations to the envi-ronment (ie, large-print books, extra setof books at home, audio books, extendedtime on tests, note takers).

If symptoms remain severe or prolonged,typically longer than 5 to 6 months, moreintensive intervention may be needed. Inthese cases, a potentially more perma-nent disability is considered, necessitat-ing most school districts to trigger theirChild Find (a component of IDEA) obli-gations, provide appropriate testing, anddevelop an IEP. The family team andmedical team should continue to be in-volved and consulted during the de-velopment of the IEP. Interventions at thislevel are often considered modificationsof the curriculum, implying that thestudent may not be held responsible forthe regular education curriculum re-quired of all other same-age peers. In-stead, the student may be taught withoutpenalty on a level appropriate for him orher, often at a level lower than peers, andwill only be held accountable for his orher own personal academic growthrather than being compared with typicalgrade-level peers.17,18 In addition, theconcussion would be so severe at thislevel as to potentially necessitate spe-cialized instruction and/or specializedprogramming. It is uncommon, however,for the student with a concussion toneed an IEP.

When considering the implementationof a 504 plan or IEP, involving the schoolacademic teams or special educationteams is beneficial and necessary. Theschool academic team, including theschool psychologist, can provide formalrecommendations to the school tomake the creation of the 504 plan or IEPthat is most relevant to the particularstudent’s greatest needs in the aca-demic setting. Regardless of the prob-lems, it is essential the medical team,the school team, and the family teamwork together, if further testing seemsindicated to help in the development ofan educational program through an IEP

or 504 plan. In the majority of theseassessments, the recommendationsand development of an IEP or 504 planwill be developed by the schools. Amedical diagnosis of concussion canprompt the school academic team tocollect other sources of information andconsider developing a 504 plan or IEP.Importantly, 504 plans and IEPs are gov-erned by different laws. A 504 plan canbe provided when a school determinesthe concussion to substantially limit oneor more major life activities, such aslearning. On the other hand, an IEP canbe provided if it is determined that theconcussion results in total or partialimpairment that adversely affects edu-cational performance such that a studentcannot benefit from regular educationalone and requires modification of cur-riculum, specialized instruction, pro-gramming, and/or placement.

Although not expected or common aftera concussion, a student with prolongedsymptoms who does not seem to beresponding to various interventionsshould also be evaluated for issuesrelated to anxiety about school or schoolavoidance. This may bemore likely in thechild who sustained a concussion froman incidence of bullying or assault.Keeping a child out of school and awayfrom friends for extended periods alsomay risk development of fear and iso-lation in a child or adolescent on at-tempting to return to school and mightrequire the assistance of a mental healthspecialist in extreme cases.

EDUCATION

Given the large number of concussionsoccurring each year, both in and out offormal sport activities, most schools willencounter a child who is dealing withsymptoms from a concussion. Educationof all individuals involved is paramountto helping students who may need as-sistance in the school setting.

Education regarding concussion, gen-erally, and the role of cognitive and

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physical rest and return to school,specifically, is essential for the teams ofindividuals helping a student with con-cussion during assessment, manage-ment, and recovery. This educationshould extend to both school personnel(eg, administrators, athletic directors,teachers, guidance counselors, schoolpsychologists, coaches, school physi-cians, school nurses, ATs) and individ-uals likely not employed by the school(eg, primary physicians, sports/teamphysicians, emergency departmentphysicians, parents, and other care-givers). Even in states with legislationfor concussion education and manage-ment, nonathletic personnel in schoolsare often left out of concussion edu-cation efforts. However, a comprehen-sive team approach to care may helpreduce mistakes in management, whichcould potentially risk reinjury during thehealing phase, lengthen recovery, orresult in untoward long-term outcomes.

Education, on a larger scale, should beconducted to instruct school groups onthe concepts of concussion management,particularly when introducing models ofcognitive rest. Education can be tailoredto various school personnel as needed.Education sessions are especially helpfulas sport seasons begin in the fall, winter,and spring. Several groups have de-veloped educational materials, such asonline tutorials, relevant to this topic andprovide excellent resources for schools,parents, students, and health care pro-viders (see Resources).

FUTURE DIRECTIONS

Given the paucity of studies that havebeen conducted thus far regardingthe effects and role of cognitive restafter concussion, further research isneeded. Future research is also neededto clarify best practices for RTL. De-veloping a better understanding of thebest methods to assist a student in theschool environment, determining whe-ther cognitive rest can assist in speed

of recovery, and evaluating written andeducational resources on this topic areall areas that require additional re-search and review. Studies comparingoutcomes in school settings that haveconcussion management teams withcase management versus those that donot would also be of value.

Continued education of all individualsinvolved with a student with a concus-sion should help facilitate better out-comes and less resistance to developingappropriate concussion managementguidelines and programs.

CONCLUSIONS AND GUIDANCE FORPHYSICIANS

1. Students with a concussion may needacademic adjustments in school to helpminimize a worsening of symptoms.

2. Given that most concussions resolvewithin 3 weeks of the injury, adjust-ments may often be made in the indi-vidual classroom setting without formalwritten plans, such as a 504 plan or IEP.

3. Students with symptoms lasting lon-ger than 3 to 4 weeks may benefitfrom a more detailed assessment bya concussion specialist (licensedphysician, such as a pediatrician,neurologist, primary care sportsmedicine specialist, or neurosur-geon with expanded knowledgeand experience in pediatric concus-sion management) and recommen-dations specific to the educationalenvironment. Considerations shouldbe given to developing a 504 plan or,subsequently, but unlikely, an IEP, inthe student with a lengthy recovery.

4. A team approach consisting of themedical team, the school team, andthe family team to assist the studentin his or her return to learning is ideal.

5. Students should be performing attheir academic “baseline” beforereturning to sports, full physicalactivity, or other extracurricularactivities following a concussion.

6. Education of all individuals in-volved with students who sustaina concussion is necessary toprovide adequate adjustments,accommodations, and long-termprogram modifications for thestudents.

7. Additional research is necessaryto strengthen and provide moreevidence-based recommendationsfor appropriate adjustments forstudents following a concussion.

RESOURCES

� Brain 101: Concussion Handbook:http://brain101.orcasinc.com/1000

� REAP (Reduce/Educate/Accommodate/Pace) Program: a community-basedconcussion management program:http://www.rockymountainhospital-forchildren.com/sports-medicine/concussion-management/reap-guidelines.htm

� CDC Foundation Online Training forClinicians: http://preventingconcus-sions.org/

� Centers for Disease Control andPrevention: Fact Sheet for SchoolProfessionals on Returning to Schoolafter a Concussion: http://www.cdc.gov/concussion/pdf/TBI_Returning_to_School-a.pdf

� Centers for Disease Control and Pre-vention: Heads Up for Schools: http://www.cdc.gov/concussion/HeadsUp/schools.html

� Centers for Disease Control andPrevention: Online Coaches Train-ing: http://www.cdc.gov/concussion/HeadsUp/online_training.html

� Dr. Mike Evans Concussions 101 Video:http://www.myfavouritemedicine.com/concussions-101/

� Frequently Asked Questions about504 Plans: http://www2.ed.gov/about/offices/list/ocr/504faq.html

� Sample Return to Learning Note forPhysicians: http://www.aap.org/en-us/

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about-the-aap/Committees-Councils-Sections/Council-on-sports-medicine-and-fitness/Documents/returntoschool.pdf and http://www2.aap.org/sections/schoolhealth/returntoschool.pdf

LEAD AUTHORSMark E. Halstead, MD, FAAPKaren McAvoy, PsyDCynthia D. Devore, MD, FAAP

CONTRIBUTING AUTHORSRebecca Carl, MD, FAAPMichael Lee, MD, FAAPKelsey Logan, MD, FAAP

COUNCIL ON SPORTS MEDICINE ANDFITNESS EXECUTIVE COMMITTEE,2012–2013Joel S. Brenner, MD, MPH, FAAP, ChairpersonRebecca A. Demorest, MD, FAAPMark E. Halstead, MD, FAAPAmanda K. Weiss Kelly, MD, FAAPChris G. Koutures, MD, FAAPCynthia R. LaBella, MD, FAAPMichele LaBotz, MD, FAAPKeith J. Loud, MDCM, MSc, FAAP

Kody A. Moffatt, MD, FAAPM. Alison Brooks, MD, FAAPStephanie S. Martin, MD, FAAP

LIAISONSAndrew Gregory, MD, FAAP – American MedicalSociety for Sports MedicineLisa K. Kluchurosky, MEd, ATC – National AthleticTrainers AssociationJohn F. Philpott, MD, FAAP – Canadian PaediatricSociety

STAFFAnjie Emanuel, MPH

COUNCIL ON SCHOOL HEALTHEXECUTIVE COMMITTEE, 2012–2013Cynthia D. Devore, MD, FAAP, ChairpersonMandy A. Allison, MD, MSPH, FAAPRichard Ancona, MD, FAAPElliott Attisha, DO, FAAPStephen Barnett, MD, FAAPBreena Welch Holmes, MD, FAAPChris Kjolhede, MD, MPH, FAAPMarc Lerner, MD, FAAPMark Minier, MD, FAAPJeffrey Okamoto MD, FAAPThomas Young, MD, FAAP

LIAISONSCarolyn Duff, RN, MS – National Association ofSchool NursesLinda M. Grant, MD, MPH, FAAP – AmericanSchool Health AssociationVeda Johnson, MD, FAAP – School-Based HealthAllianceMary Vernon-Smiley, MD, MPH, MDiv – Centersfor Disease Control Division of Adolescents andSchool Health (DASH)

CONSULTANTSGerry Giola, PhDK. Brooke Pengel, MD, FAAPKeith Yeates, PhD

STAFFMadra Guinn-Jones, MPH

ORGANIZATIONS THAT HAVEENDORSED THIS REPORTAmerican Medical Society for Sports MedicineBrain Injury Association of AmericaCanadian Paediatric SocietyNational Association of School NursesNational Association of School PsychologistsNational Federation of State High SchoolAssociations

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2. Zonfrillo MR, Master CL, Grady MF, WinstonFK, Callahan JM, Arbogast KB. Pediatricproviders’ self-reported knowledge, practi-ces, and attitudes about concussion. Pedi-atrics. 2012;130(6):1120–1125

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14. Piebes SK, Gourley M, Valovich McLeod TC.Caring for student-athletes following a con-cussion. J Sch Nurs. 2009;25(4):270–281

15. McGrath N. Supporting the student-athlete’sreturn to the classroom after a sport-related concussion. J Athl Train. 2010;45(5):492–498

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18. McAvoy K. Providing a continuum of carefor concussion using existing educationalframeworks. Brain Inj Professional. 2012;9(1):26–27

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