Return to Learn - Teacher Tips for Concussion Management  

December 03, 2017

As we settle in to the second quarter of the school year, I thought it would be a good time to refresh upon concussion management and the importance of how to assist students returning to learn as part of their recovery. For some educators (especially coaches) the reality of concussions (i.e. mild brain injuries) has already been on the forefront as sporting practices and events have been underway since August. However, sports are not the only method in which students can acquire a concussion or traumatic brain injury. Accidents and falls are the leading causes of traumatic brain injuries in elementary-age children. This includes accidents that occur during recess and/or PE class as well as outside of school.

The purpose of my article is not to focus on the incidents that can cause a traumatic brain injury, but rather to provide information to educators and parents about how to assist students as they recover and return to school and academics. The Return to Learn policy was developed as a guide for Nebraska school districts to develop a protocol for students who have suffered a concussion. Since 2014, all schools are required to have a Return to Learn protocol.

Before I discuss specifics regarding transitioning back to school and accommodations in the classroom, here are a few important tidbits:
• The recovery period for most concussions is 1 to 3 weeks.
• Most students should be able to return to school after 2 or 3 days of rest at home. However, parental monitoring of the student’s symptoms will determine when they are able to return.
• Students should be able to tolerate 30-45 minutes of light mental activity before returning to school.

Upon returning to school, the Concussion Management Team (CMT) along with the student’s parents should develop a gradual Return to Learn protocol that is tailored to the student’s individual needs. Recent research has found that getting back to the classroom early on after a concussion is more beneficial than being absent for a longer period of time. Students who were absent from school for more than a couple days often suffered from increased depression or anxiety which in turn hindered their recovery process. 

School Schedule-

This being said, precautions should be taken when determining how long a student should spend at school after a concussion. Parents and the student should be able to provide information in regards to how the student has felt throughout the past few days in order to determine a start-back schedule (i.e. whether they have a headache first thing in the morning or possibly start to tire in the early afternoon). The student may need to start back to school on a shortened schedule or be dismissed early. Also, it is mandatory that the student sit out of physical activities until cleared by their physician. Other items to discuss may include:
• Sensitivity to light and sound. (Students may need to be excused from band class or be excused early from class to avoid loud/crowded hallways. Lighting may need to be adjusted in classrooms.)
• Assigning a designated area for the student to take rest and/or mental breaks.
• Changes to class schedule: alternating core (or challenging) courses with elective courses in order to allow the brain time to rest.

Workload –

The CMT will also need to determine an appropriate process for make-up work as well as daily assignments and tests. Just as with other muscles, the concussed brain needs time to heal before it’s able to return to ‘normal’ functioning. Teachers should not expect students who have recently returned from a concussion to be able to academically perform as he/she did prior to the concussion. The student’s Return to Learn protocol will need to address: 
• The amount of daily work the student is assigned and/or expected to complete each day. (This may vary depending on the student’s courses, etc. Also, teachers may need to ‘take turns’ on assigning work.)
• Modifications to daily work (i.e. creating a presentation versus writing a written report).
• Modifications to tests and quizzes (i.e. multiple choice versus open-ended questions).
• A time line for completing missed work (if necessary).

Teachers will also need to continually monitor the student for an increase in their concussion symptoms while they are completing class work or taking tests. If the teacher notices (or the student indicates) an increase in concussion symptoms, there may need to be an adjustment to how much work is assigned or expected. Close observation and data collection will also assist the student’s physician in evaluating their cognitive healing process. 

Symptoms Management – 

Several concussion symptoms are easily observed by others – difficulty concentrating, emotional symptoms, and fatigue. However, students may also exhibit other concussion symptoms that are not as easily noticed – a slower processing speed and/or issues with working memory, etc... All symptoms impact both the student’s healing process as well as their academic performance. Teachers will also need to monitor the student for changes in these symptoms (as identified by the student, parents, and CMT). Below are several common concussion symptoms with possible strategies and/or accommodations that teachers can use in the classroom.

• Attention/Concentration
o Utilize consistent schedules for activities to create a sense of predictability.
o Break larger tasks into smaller segments. Give the student 1-2 smaller segments at a time.
o Utilize redirection strategies. Provide student with a verbal or visual prompt to remind them to pay attention or focus.

• Fatigue
o Provide set rest times throughout the student’s day (morning and afternoon). 
o Allow the student to use sensory supports (i.e. sunglasses, headphones, etc.) to help with increased sensitivity.
o Carefully monitor student so that he/she does not become over fatigued. 


• Working Memory
o Utilize external reminders (such as student planners, notecards, etc.) to assist the student with remembering important dates and information. Memory problems may be inconsistent – the student may know something one day and not the next. 
o Determine what is “most important” concept or idea that the student needs to learn/know from the material being presented. 
o Relate new concepts/learning to what the student already knows.

• Slower Processing Speed
o Provide the student with copies of notes, agendas, etc. to allow him/her to focus on the content of learning; not the structure of how it’s presented.
o Utilize checks of understanding. Ensure that the student understands the directions, information, etc. before moving on to new/other things.
o Allow for extended time to process information.
o Adjust due dates for larger projects/assignments to allow for additional time to complete.

• Emotional Symptoms
o Monitor the student for signs of frustration, irritability, being overwhelmed, etc. 
o Listen to the student and provide reassurance. 
o Utilize school counselors and/or school psychologists as additional resources and supports. 


The recovery time for most concussions is 3-4 weeks. Students will obviously vary in their recovery rates. Some may experience increases in concussion symptoms throughout their recovery process. It is extremely important that teachers carefully monitor student progress in order for the Concussion Management Team (CMT) to make appropriate adjustments to the student’s plan throughout their recovery period.  Effective communication (between the student, parents, school staff, and medical personnel) is also an essential part to a successful Return to Learn protocol. 
For additional information (including examples of forms), please access the following websites:

• Nebraska Department of Education - BIRSST Information: https://www.education.ne.gov/sped/birsst-brain-injury-regional-school-support-teams/
• Nebraska Department of Education – Return to Learn: Bridging the Gap…: https://www.education.ne.gov/wp-content/uploads/2017/07/BRIDGING-THE-GAP-Booklet-plus-Appendices.pdf
• Brain Injury Alliance Nebraska – REAP Manual:  http://biane.org/concussion/reap-manual.html
• Center on Brain Injury Research & Training: https://www.education.ne.gov/wp-content/uploads/2017/07/BRIDGING-THE-GAP-Booklet-plus-Appendices.pdf

If your district needs information or assistance with creating a Return to Learn protocol for a concussed student, your ESU10 school psychologist is an excellent resource! You are also welcome contact me for assistance as I am ESU10’s representative on the central region’s Brain Injury Regional School supports Team (BIRSST). 

REFERENCES:
• Brain Injury Alliance Nebraska – REAP Manual for Concussion Management. Retrieved from http://biane.org/concussion/reap-manual.html.
• Nebraska Department of Education – Return to Learn: Bridging the Gap from Concussion to the Classroom.  https://www.education.ne.gov/wp-content/uploads/2017/07/BRIDGING-THE-GAP-Booklet-plus-Appendices.pdf.
• The Center on Brain Injury Research and Training. Retrieved from https://cbirt.org/back-school/return-school-plan.

-by Nicole Shimek-Langrud, School Psychologist