April 12, 2017

Medical professionals, state agencies and community partners look to develop new guidelines for concussed students

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Concussions are an invisible injury that can cause physical, cognitive, emotional and sleep symptoms that last for varying lengths of time depending on the nature of the injury. Changes in behavior, mood, learning and thinking that may be a result of a head injury can be misunderstood — making transitions into the classroom postconcussion difficult for students and teachers.

concussions classroom graphicRecognizing symptoms of a concussed child goes beyond the physician, coach and parent. Educators should be involved in the process of a child’s ability to return to the classroom and develop a school concussion management plan, says Laura Dreer, Ph.D., director of concussion research in the University of Alabama at Birmingham Sports Medicine Concussion Clinic at Children’s of Alabama and co-chair of the Alabama Return-to-Think Task Force.

On Friday, March 24, Dreer and her co-chair from the Alabama Department of Rehabilitation, Maria Crowley, met with the Alabama State Department of Education to build on their task force to identify guidelines that will instruct educators on the appropriate measures to take when a student is suffering a concussion.

“We are looking to better develop a plan for training educators on the dangers of pushing concussed children too far in the classroom, similar to what has been done nationwide with Return-to-Play policies for academics,” said Dreer, an associate professor in the UAB Department of Ophthalmology. “Currently, eight states have Return-to-Think guidelines to help educators know when it is appropriate for a child to start learning and at what pace.”

Return-to-Think is the process of returning to cognitively stimulating activities following concussion. Immediately following mild traumatic brain injury, a concussed child should have a period of complete cognitive rest from activities that demand cognitive exertion, including homework, videogames, television, computer work and cellphone screen time. Cognitive activity should progress to the gradual resumption of the activities and full participation in the classroom following symptom resolution.

“Dr. Dreer brought attention to the dangers of concussed students’ and the elements of schoolwork and activities in the days following a concussion during a presentation to school nurses across the state,” said Jennifer Ventress, nurse administrator for the Alabama State Department of Education. “We recognized the importance of developing a standardized process and set of tools, based on the best available evidence, that school personnel could use to assist students during this process. Building a task force to intently focus on the appropriate measures to integrate children back into the classroom after traumatic injuries was the logical next step.”

Return-to-Think guidelines will assist educators in developing a concussion management plan. Concussion management involves several systems of care: school, medical, sport/recreation, and family/student. The guidelines will inform educators on what a concussion is, how it impacts schoolwork, overall management of a concussion and how to adapt the classroom for concussed students, in order to develop a concussion management plan.

“The task force will encourage educators across Alabama to decide on a school concussion management plan before the 2017-2018 school year begins,” Dreer said. “In the case of a concussed student, these guidelines can be referenced as the student returns to physical and mental activities.”

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Within the concussion management plan, a designated person at the school should be assigned to facilitate dissemination of information between systems of care. This enables all symptoms to be monitored and progress to be communicated between systems of care for the student.

Educators should be able to recognize symptoms of a concussion that interfere with academic performance. Examples of concussion symptoms that may impact participation in academic tasks include:

  • Becoming easily fatigued in the classroom or over the course of the day
  • Being bothered by bright florescent lights or loud noises in the classroom and in crowded areas, such as the playground or cafeteria
  • Being easily distracted
  • Nausea during classes or physical activity
  • Difficulty concentrating on coursework or homework
  • Reading slowly and difficulty with comprehension
  • Experiencing a headache while working on schoolwork which may worsen with prolonged concentration
  • Having trouble remembering learned information
  • Experiencing frustration or irritation with peers, educators and/or family members
  • Difficulty reading due to vision problems

“The first step in creating these guidelines is being able to recognize these signs and symptoms of concussion in a student,” Dreer said. “Recognizing how a concussion can affect a student can impact the overall treatment plan moving forward.”

Once a concussed student is ready to slowly get back into learning, the Return-to-Think task force is identifying potential accomodations educators can adapt the classroom to fit their level of progression, which may include:

  • Reducing schoolwork demands to a level that is manageable for the student, including no or reduced homework or course load depending on symptom severity.
  • Scheduling and allowing rest periods and breaks.
  • Providing a quiet place in the school to take a break, complete work or take exams.
  • Removing the student from recess and physical education activities where risk for an additional concussion is elevated.
  • Allowing the student extra time on coursework, tests, quizzes and/or homework assignments.
  • Reducing light sensitivity by allowing the student to wear sunglasses.

These types of accomodations are being discussed in terms of standardized protocols that school systems might consider using. 

“The most important part of getting back to a classroom for a concussed student is slow progression,” Dreer said. “If educators understand the complications a student is experiencing and knows how to better accommodate them, the student’s brain will heal faster.”

Dreer’s concussion research efforts at UAB and Children’s of Alabama continue to explore predictors and barriers in traumatic brain injury. Evidence is continually becoming available, and guidelines will continue to evolve.

Dreer, a licensed neuropsychologist, and her multidisciplinary team are well-equipped to continue to provide training efforts to interested school, medical and community systems around the state to learn how to better detect and manage concussions. The development of this task force will help educators stay informed of best practices to help students maximize recovery.