Some of the most important posts will be re-published from time to time. This one was published in October of 2010.
In the most recent Journal of Athletic Training, Neal McGrath was published about the accommodations that may need to be made for concussed students. This topic is one that is commonly overlooked by those that care for the student-athlete that has a concussion. The every day tasks of walking in a hallway at a high school can be very difficult.
Below are the accommodations that were suggested, if you jump to the article you will see the rationale for each.
- Excused Absence
- Rest Periods During Day
- Extension of Assignments
- Postponement or Staggering of Tests
- Excuse from Specific Tests
- Extended Testing Time
- Accommodations to Sensitivity to Noise/Light
- Excuse from PE/Sports
- Avoid other Physical Exertion
- Use of Reader for Tests/Assignments
- Use of Note Taker/Scribe
- Use of Smaller/Quieter Testing Room
- Preferential Classroom Seating
- Use of Tutor
The Concussion Blog 
Dustin,
The link to the article is not working.
I need to read the article so I do not know if this is included, but one of my major concerns, as well as the athletes who I see, is the pressure they get to “make up” all the work they missed while they are recovering. This, again, is an issue of not understanding the injury and the recovery process. Teachers need to know that making up any missed assignments needs to be postponed till the child has made a FULL recovery, and then the work can be made up slowly, not all at once.
If students are symptomatic, then it seems reasonable that the student should not be engaged in an activity…and be at cognitive, emotional and physical rest.
For example…if a student is sensitive to lights and noise…why further stress the injured brain by having him/her engage in academic or scocial activities where the light is causing physical stress on the brain?
Furthermore…asking to make-up missed asisgnments may cause cognitive and emotional stress as the person is “running on” reduced energy and physical abilities…and thus over- tax an injured brain.
What about suggested accommodations based on grade level (such as early elementary, intermediate, middle school & high school)? These students have slightly different needs and concerns (young children still learning to read/basic math concepts, older teens worried about grades/standardized tests for college). I like the suggestions Meehan makes in “Kids, Sports, and Concussion,” about focusing on keeping up in subjects that build upon themselves, such as mathematics and science (although, those subjects might be more likely to result in cognitive strain), and letting the subjects that can slide a little (I think most parents who review their kids’ homework have noticed there are often assignments that aren’t necessarily critical – again some of this depends on grade level – personally, I suspect younger kids could go 1/2 days until they’re just about fully recovered without harming their academic futures).
It would be nice if representatives from the professional groups responsible for treating students with concussions (athletic trainers, pediatricians, sports specialists, etc.), worked with the federal/each state department of education to create standard guidelines/protocols for accommodations that could easily be modified based on students’ individual needs. It’s too difficult for individual doctors, parents, and students to work these issues out (or sometimes battle out) with school personnel without prior knowledge of the need for accommodations.
As a special concern for younger students, although some doctors suggest students be allowed to go out to recess, I think the reality is that there often isn’t adequate supervision. At our school, it’s not unusual for a handful of teachers/teaching assitants to be responsible for watching over 100 kids on the playground. (Since my son recovered, he’s been pushed down a number of times during recess.)
Initial thoughts…
— accommodations based on grade levels take away from/ignore the individual needs, and corresponding abilities and possible deficits of each student…
Standardized guidelines would serve to contradict individual needs…and seems to be a repeat of the numerous RTP standards that are not scientifically based…and are merely opinions.
Futhermore, a point that seems to be ignored is that there are many faces / cluster of symptoms of a concussions. Thus effective treatment cannot be found via a ‘simple’ guideline template.
— creating cognitive [and emotional and physical[ strain seems counter intuitive to complete and adequate rest…a student may have to miss school for a period of time…to protect all areas and functions of the brain. For what ever reasons…it seems some people do not wish to have a student miss ‘much school’…regardless of the level of ‘mild’ brain injury sustained…and the need for the student to thoroughly convalesce.
— parents, doctors and others need to be prepared to advocate for the suffering athlete…it is the moral [and most likely eventually, legal] responsibility of the adults who sanction the youth’s sport participation…as there are risks/benefits of sport participation that must honestly be acknowledged by adults.
–re recess issue…suggest alternative and restful activities be sought via 504 accommodations.
I imagine there is great variability in how schools respond to requests for academic accommodations. In my son’s situation, the school didn’t know how to adequately implement the doctor’s instructions for a reduced workload and time for rest periods/naps (his symptoms were vestibular in nature, and he was able to perform well in school – although school work did result in approximately 1 to 2 headaches per school day – his balance issues were only evident during postural stability testing, and the school didn’t believe me when I told them he was struggling with fatigue and wanted to rest as soon as he got home – they didn’t believe him about his headaches either – actually, they thought the doctor might be mistaken about his balance issues too).
Based on conversations I’ve had with doctors, some teachers push back against suggested accommodations (they don’t see a need for it, and believe the student is trying to get out of work). My son’s situation reached the point where I felt it was necessary to contact a lawyer – I was told he had missed enough time from school and that he couldn’t leave early anymore. (If I had known more about concussions, I would have been a better advocate from day one – I tried to do the right things …)
The reason I suggested grade level guidelines was because much of the information on academic accommodations I’ve read seems to be geared towards high school athletes. I think younger kids have different needs (also recognizing that each individual has unique needs based on symptoms, etc.).
My perspective is limited to the problems my son had. My goal is to make it less likely that other children will have similar negative/potentially harmful experiences. I’ve seen a real lack of understanding with school personnel, and a lack of ability to meet the students’ needs – that is what I would like to change. Parents and doctors need to advocate for the student, but they shouldn’t feel the need to get legal representation. I may not have the best answers for fixing the problems, but I know there are problems that need to be addressed, and I believe there would be benefits to tackling the issue from the top down rather than leaving it to parents and doctors to battle things out on a case by case, teacher by teacher basis.
I agree with your Sport-Related Concussion management guidelines that Dustin has linked to. I just feel we are so, so far away from those. I hope my initial response didn’t sound argumentative. (Dustin knows more about what happened in my son’s situation … the details explain why I’m trying to at least make it somewhat better for other concussed students.)
Thanks for providing feedback.
Don’t believe you are being argumentative.
School personnel may not believe you…thus the need for medical support/documentation for your concerns.
504 accommodations are law and binding…not just ‘feel good ideas’.
Sadly I once heard a knowledgeable parent state that school districts lose state aid money when students are absent…thus there is always a concern re conflicts of interests exiting re school-related decision making for students…
An example of a plausible conflict of interest follows: allowing a student to be excused from school and lose state money… or not grant 504 accommodations for being excused from school and earn money…
Does your State have State Educational reps who will listen to, and advocate for, parents and student 504 Plans and disability issues (i.e., special education)? Does your state require a parent rep to be present for all special education and 504 accommodation meetings?
From my perspective, and related to the content of your postings…your thoughts and experiences provide the rationale why parents MUST strongly advocate for their children…as ignorance re concussions exists at many professional levels and within many professional disciplines.
Thanks for your suggestions. My son is fine now, we’re just being careful about what physical activities he participates in to avoid reinjury.
His pediatrician provided the school with medical documentation and instructions. They didn’t know how to implement the instructions, and since he was getting good grades, they assumed he really didn’t need cognitive rest (they wanted to push him to learn as much as possible while he was recovering so he wouldn’t get behind, just as they wanted to make him walk at gym and recess so he wouldn’t get out of shape). When his symptoms persisted longer than a couple of weeks, they assumed he had to be lying because they so strongly believed he had a mild concussion which should have cleared in a few days.
People generally make better decisions when they’re informed. A lack of awareness caused normally reasonable individuals to behave in an unreasonable manner, and to make poor decisions. I would like to see our department of education prepare model concussion management guidelines that would help ensure schools are better prepared to meet the needs of concussed students. Even with such guidelines, parents and doctors will still need to be advocates.
Teachers need quick and easy to interprete guidelines covering basic issues – like no standardized tests, don’t make children read during rest time, no band (my daughter told me about a concussed classmate who struggled to play his instrument), etc. Once the very basic issues are covered, then it should be easier to make an individualized plan.
The 2 SRC articles my wife, Flo, and I wrote and were published online by NASP during 2011 have excellent references that provide some important historical info re concussions. Suggest you read the writings of Dr. Evans and Dr. Gronwall that are cited.
Gronwall conducted concussion research during the last century. Among her and colleague findings was that although a person performed ok again on tests after suffering a concussion, more of the person’s brain was involved in completing the tasks. In addition, during the 1970’s she co-authored an article re the cumulative effects of SRCs.
Finally, a problem that exists with a pediatric-related concussion follows …previously undetected brain dysfunction may appear during a later developmental period.
I am concerned about unrecognized cognitive impairment and possible developmental issues (is it Dr. Omalu who’s said that football can preclude a child from obtaining full capacity of his cognitive/intellectual functioning). If I could turn back time, I would. Since I can’t, I’m going to do the best I can to help prevent additional injuries (no more football or wrestling).
I recognize the need for cognitive and physical rest immediately following a concussion, but wonder if there are any post recovery exercises/activities to improve brain function. Based on my sister’s experience with MS, I know plasticity allows the brain to compensate for lost function (MRIs revealed extensive plaques/lesions – doctors were surprised by her level of function). She exercises daily to help retain as much function as possible (of course, she also has to avoid stress and becoming overly tired).
It would be helpful to know if there are any post concussion therapies that could be used following the initial recovery period. I don’t think I’ve come across any research in that area.
There is a program here in PA that is part of the Intermediate Unit called Brain STEPS. It’s purpose is to put a framework of protocols in place for students returning from head injuries who appear to have a protracted recovery. It essentially is providing a formal “temporary” IEP/504 kind of protocol that a student’s teachers have to abide by. It also makes sure that everyone is coordinating their efforts (Athletic Trainer, Nurse, Guidance Counselor, Teacher, etc.)
While initial recovery protocols (for the usual 7-14 day recovery periods) are usually simple (initial complete rest, return slowly to activity/academics). Long term issues can be far more subtle.
One serious issue with long term recoveries (and subsequent academic/athletic accommodations) is that it appears that even physicians can’t agree on what is “proper”. I spoke with someone who attended the recent TBI hearings in DC, and there were several people who testified to a startling statistic. They are finding that about 50% of neurologists are clearing athletes during longer recoveries (a couple weeks to months) back to full participation even though still symptomatic (usually memory and learning related). The prevailing reasons given in most of those cases iare that after they feel the Second Impact risk is over they apparently don’t seen any enhanced risk if there are lingering cognitive effects dealing with memory and learning.
So essentially those doctors feel that while a student is obviously struggling from long term affects in the classroom, feel free to go bang your head around on the field. Hypocritical, and hopefully something the medical community will reign in before too long.
I am not a huge fan of 504’s in the first three weeks of recovery… The main reason being they can be very UN-flexible and initially the problems that would require actual long-term accommodation may not be apparent…
I have also experienced these general issues with 504:
– parents resistant to “label kids”
– school personnel find it “time consuming”
– schools typically place 504’s in special education classes or assume they do
We truly try to use as much common sense as possible with regular communication and problem identification and resolution in the first few weeks…
And what I referred to above is NOT a 504 plan. I was just saying the Brain STEPS frameworks resemble the way IEP/504 plans dictate class room modifications (if any).
Looks like there may be some good aspects to the program, it includes “Brain STEPS 101” presentations to compensate for lack of brain injury training for teachers.
Click to access Fact_Sheet_rev_08192008.pdf
It would be interesting to hear how successful it has been. I’m curious as to whether or not it only comes into play with more severe head injuries (is it difficult to get referrals?).
I can speak to the wonderful job the BrainSteps program has done in our school district. BrainSteps representatives can help school administrators, counselors, psychologists, faculty & staff to understand the ramifications of TBI and why academic accommodations are necessary. There are a large number of things that can be done and if necessary, a 504 plan needs to be put in place for student. A link to BrainSteps:
http://www.biapa.org/site/c.iuLZJbMMKrH/b.3486877/k.6F10/School_ReEntry_BrainSTEPS.htm
This does look like a good program. I am a teacher and also the mother of a son who is still struggling 16 months after his injury. I was completely uneducated as to the possible long lasting affects of a concussion and certainly never received any training on how to assist students who may be struggling. Identifying these kids and training educators how to help them in the academic world is so important and yet it does not seem to be the “in thing” to talk about. “Return to play” is all the rage in concussion conversations with little emphasis on “return to academics”. When I try to help my son by discussing professional athletes struggling with the same symptoms as him, his response is that they have already finished their educations, already have/had a career and many have already made their millions. He has done neither. He was once an honors students who can barely pass a test now. It has taken more than a year to get his school on board. I think it had more to do with their lack of education and training in this area than simply not caring. We desperately need a way to connect educators and families to the information that can help transition the kids through this difficult time in their lives. My son cannot take a season off, take a leave of absence from work, or take a semester off college. He has one shot at high school and that one shot will impact his college and career choices. That in turn impacts who and what he will be. Maybe Pennsylvania has it right. If the schools will really abide by the suggested accommodations, then kudos to them for teaming up with experts to help these kids rise above their injury to attain academic success and a better chance at the future they wanted to have all along.
I’m sorry to hear your son is struggling with post-concussion symptoms for such an extended period of time. Many who read and comment here have extensive experience with students suffering from concussions, and they may be able to provide helpful suggestions. Dustin has included a number of links to really helpful sites. If you haven’t had a chance to check them out already, I would suggest clicking on the MomsTeam, SportsConcussions.org, and Sport Concussion Library links. Of course, you can also find a lot of informative past entries here under the categories heading.
Hello! I stumbled upon your responses about the BrainSTEPS Program, and I actually oversee BrainSTEPS. We have a website http://www.brainsteps.net full of videos we have created. We cover the state of Pennsylvania with 30 teams comprised of over 300 professionals (medical and educational) who are based out of the educational Intermediate Units. BrainSTEPS is jointly funded by the Departments of Health and Education. Not only do we do a lot of concussion work, we will work with any student who has any severity of acquired brain injury that impacts school. We are beginning our 6th year of academic consulting and training. BrainSTEPS created a Concussion Return to School Protocol with the PA Dept of Education a little over a year ago and assist districts on all aspects of concussion recovery. We created a specific Brain Injury Supports Framework (mentioned above) that we use with districts, families and students to link their symptoms to accommodations. Our consulting team members have a wealth of unique accommodations to employ, assisting the district understanding of concussions. Consultants implement the framework as soon as a referral is made to BrainSTEPS. It then is continually monitored for needed adjustments until symptoms resolve. If student symptoms do not resolve over time, we assist districts in identifying more formal modifciations that may be necessary long term. Our program work surrounding concussions focuses on building the local school district capacity to manage concussions during the first 4 weeks (unless the concussion is more complex) and then at 4 weeks, the BrainSTEPS referral is warranted to assist. I have seen many distinct patterns emerging such as: make up work versus new learning, how do you modify AP/honors coursework at 50% for several months, can a student return to play if they still require academic accommodations at school, how can a student who has been on homebound for weeks to months recoup credits to graduate ontime…..BrainSTEPS helps with these issues! This summer I was invited to sit on an expert panel on concussions in schools at the Centers for Disease Control in Atlanta, GA. There are many good things coming out this year regarding district assistance for managing concussions. If anyone is interested in more information, feel free to contact me at: eaganbrown@biapa.org
Thank you for commenting here. I hope other states work on similar programs. Right now, it seems as though there’s no uniformity between states, or even between schools within a state. It’s good the hear that the CDC is working on this (we had a nightmare experience with the school after my 8-year-old was injured, and it’s difficult to repair relationships once a situation is allowed to progress to a certain point).