"˜Return to school' criteria vital for kids' concussion recovery

WASHINGTON – Return to school following a concussion for children and adolescents should be decided based on the type and severity of their symptoms, their age, academic course load, and how much rest they’ve had since the injury occurred, according to a study in the British Journal of Sports Medicine.

The systematic review, conducted by international leaders in the study and treatment of youth concussions, collected all available research on when and how a child should return to school following a concussion and the types of accommodations schools can make to facilitate that return.

“Historically, research has focused on getting kids back to the playing field safely after concussion,” says Gerard Gioia, Ph.D., division chief of Neuropsychology and director of the Safe Concussion Outcome, Recovery and Education (SCORE) program at Children’s National Health System. “But school, not sport, is the primary ‘work’ for children and adolescents, so getting them back to school and social contact is crucial, even if still symptomatic and accommodations need to be made as they continue to recover.”

The study authors, including Dr. Gioia, identified several common factors that should be taken into consideration when deciding if a child is ready to return to school:

• Type and severity of symptoms
• Age
• Course load
• Amount of rest available

The experts also found that, generally, a brief absence from school with academic accommodations upon return to school can help students successfully re-integrate into the classroom without exacerbating their condition. There was consensus on several recommendations that may help schools, doctors, and families work together in developing a successful individualized recovery plan.

• Schools should develop concussion policies ahead of time. Those that do tend to make more academic accommodations available to students who need them.
• Physicians should provide a “return-to-school” letter to parents at diagnosis. That letter should outline symptoms, safety restrictions and recommended accommodations, including any anticipated school absence.
• Close ongoing monitoring of recovery by care providers is necessary. This should be coupled with regular communications between provider, family and school to tailor the return to school based on the child’s individual needs and recovery trajectory.
• Specific deficits in vision or to the vestibular ocular reflex can indicate the need for additional accommodations. Physicians need to screen for these particular symptoms as they may require more academic accommodations.
• More and better research is needed. Specifically, researchers and clinicians need to define basic criteria for how long a student needs to be absent from school, and also determine some of the most effective accommodations schools can provide for either typical recovery trajectory or more prolonged recovery period.

Though the existing research shows that students who receive accommodations at school such as rest periods or reduced exposure to artificial light seem to have less complicated recoveries, none of the studies looked specifically at which accommodations worked the best.

This point reiterates something the authors stressed—the need for additional, more robust research into the specific factors that play into a return to school. They also noted many of the existing studies had limitations to their generalizability, including the potential for bias in sample selection such as samples from specialty concussion clinics made up entirely of patients with the most severe symptoms.

“We know a lot about when kids should return to sport, thanks to the research,” says Dr. Gioia. “Now we need to dedicate resources and focus to setting some baseline recommendations for doctors, parents, children, and their schools to develop care plans that will allow a child to heal while maintaining some semblance of their academic activities as well.”

He continues, “Though the existing research is limited, we were able to collect some really vital information about one key point: the importance of schools, parents, kids, and healthcare providers working together and talking together throughout the recovery process. I’d encourage every school system and every parent to educate themselves on the symptoms of concussion, and learn more about how to successfully re-integrate recovering students into the classroom. It well help everyone be better advocates for sound concussion policies.”

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