It is great news that 49 States have passed some level of “Return To Play” (RTP) concussion laws. Now it is my hope is that everyone’s attention will turn to the process by which concussed students return to school aka “Return To Learn” (RTL). Of the 49 States with RTP Laws, less than 25% of these states have any explicit inclusion of academic supports.
Since I am interested in the wide range of school concussion management plans that exist, I have been researching and summarizing the best “Return To Learn” resources that are currently available online for free.
I wanted to share these suggestions for RTL language in this blog post for anyone working to proposed a bill to update their state’s current concussion laws. To suggest some language for this effort, I have researched how number of states have handled Return to Learn and spoken with a number of experts in the field.
Please note all footnotes and credits – I do not take credit for creating any of the language below, but I merely have organized other experts’ words into sections with links back to original sources to further educate anyone interested in the topic to update their state’s laws.
Please find this post divided into four sections:
1. Colorado State’s Suggestions for Best Practices concerning RTL – a basic, concise version of RTL that could be used for any state’s Return To Learn bill
2. Additional suggestions from my research which could be added RTL section for a RTL bill
3. Sources and Additional Documentation for RTL bills and the additional suggestions in Section 2
4. List of RTL Resources for Parents, Teachers, Administrators, Healthcare Providers and Free Training Videos
SECTION ONE: A Colorado’s Law – a concise version of suggestions for RTL Law
Here is Colorado State’s Suggestion for Best Practices, with my suggestion for additional language in red:
Suggested Best Practices for Colorado’s Schools for Return to Learn
Note: These guidelines are not required by Bill SB 11-040 but should be considered:
SB 11-040 does not speak to the school district’s role in this section. Best Practice suggests that school districts create a Multi-Disciplinary Team Approach to Concussion Management including:
- A seamless system of communication between school professionals, medical professionals and the family. Information must flow smoothly from within the school to outside the school so that the RETURN TO LEARN plan followed by RETURN TO PLAY decisions can be made safely.
- A seamless system of communication among school professionals. Information must flow smoothly between the school athletic departments and the academic departments to ensure appropriate physical and academic adjustments during the recovery.
Best Practice suggests that a school create a concussion management system that is adequate and consistent for any student, elementary through high school, who has sustained a concussion regardless of the setting or mechanism.
Best practice also recommends that a school district create a system in which a student may receive a more intensive assessment and intervention, if the concussion does not recover in a reasonable amount of time. This may include formal accommodations and/or modifications of curriculum.
Taken with one modification page 9 from this source:
SECTION TWO: Additional considerations which could be suggested to make a more robust RTL section for the CT bill
Here are some suggestions which could be included in RTL Bill:
1. Suggestion for Return to Learn to be completed BEFORE Return to Play
- In concussion management, both RTP and RTL are common and important terms, but they are not parallel processes. 2 Student athletes are STUDENTS first. It is suggested that Return To Learn goals of “full school day with no accommodations” should be achieved FIRST before athletic returning to play guidelines are commenced.
2. Suggestions for Schools to have a Concussion Management Plan (CMP) in place
- When a student returns to school following any injury, the school team’s responsibility is to (a) assess the needs, (b) design an intervention plan, (c) monitor the effectiveness of the plan, and (d) adjust and readjust until the student no longer has special needs resulting from the condition. Returning a student to school following a concussion is no different. 2 It is suggested A “Return to School” Program should be accurately planned so any needed accommodations for the student begin as soon as the student returns to school. This suggested “front-loading” of academic adjustments helps to avoid complications and prolonged recovery on the back end. The student will experience the ability to cognitively exert more and more each day, while flaring less and less symptoms.2
- During the recovery period, it is suggested that students should be monitored in an scheduled, concrete way by medical and academic staff in the school until the student is fully recovered. Concussion management plans will be different for each child and even for each concussion; and it is suggested any plan should be designed with that flexibility in mind. Note: Unlike Return to Play decisions, students don’t need to be “cleared” by a physician to return to school so doctor’s note and instructions may or may not be available in initial period of student’s return.
3. Suggestion for School Staff Training
- Because students physically look well, it is not uncommon for teachers and other school officials to underestimate the difficulties that a student is experiencing and may downplay the need for cognitive rest. Education of teachers, counselors, and school administrators regarding the cognitive effects that a concussion may have on a student is important. 5 Educators are encouraged to seek out concussion accommodation training through the many resources available on the web and through continuing education programs.
SECTION THREE: Documentation for updating Concussion Laws and the additional suggestion
Why does our state need to update our Concussion Law to Include RTL?
“A concussion is an academic injury, in the sense that it affects the capacity for learning,” said pediatric neuropsychologist Gerard Gioia at the Children’s National Medical Center in Washington. “There are rarely times in school when these concussion issues do not have some potential effect on a kid’s grades and academic pursuits.” 1
In the US, 48 States have now passed laws that call for physical rest following a concussion so called Return to Play Laws. In the rush to pass RTP laws, the student-athlete was viewed as an athlete first and less than 25% of these states has any explicit inclusion of academic supports in the RTP focused laws enacted from 2009-2013.7
In just the past few years, experts in the field of concussion have come to the realization that cognitive demands, much like physical demands, can worsen symptoms and can delay recovery (Majerske et al., 2008). 2
How can a Concussion affect Learning?
“The effects of concussion on a student’s return-to-school experience are unique to each student. In most cases, a concussion will not significantly limit a student’s participation in school; however, in some cases, a concussion can affect multiple aspects of a student’s ability to participate, learn, and perform well in school. In turn, the experience of learning and engaging in academic activities that require concentration can actually cause a student’s concussion symptoms to reappear or worsen. Given this inter-relationship, and the way concussion effects can vary across students, academic adjustments need to be tailored to each student’s specific circumstances” 3
In concussion management, both RTP and RTL are common and important terms, but they are not parallel processes. 2
To date, there are no agreed upon formulas for return to learning (RTL). This is due largely to the fact that the return to school following concussion is an extremely individualized process 2
Students must receive academic accommodations that need to be adjusted by school personnel in collaboration with managing medical professional until full recovery. The school psychologist and/or the school nurse are uniquely poised to facilitate the transition of a student with a concussion from the medical setting back to the educational setting. 2
Since a concussion is a medical event, and its recovery spans the home and school setting for 3 or more weeks, the management of the concussion is best accomplished by a seamless system of communication and collaboration among parents, the school, and the healthcare providers. 2
This multidisciplinary team approach to concussion management lends itself to consensus decision-making. It is best practice that the concussed student always returns to school with a signed release of information in place allowing for two-way communication between the school and the healthcare provider. 2
Many athletes will report increased symptoms with cognitive activities after a concussion, which makes intuitive sense because the concussion is a functional rather than structural injury of the brain. Athletes with concussion often have difficulty attending school and focusing on schoolwork, taking tests, and trying to keep up with assignments, especially in math, science, and foreign-language classes. Reading, even for leisure, commonly worsens symptoms. 10
To prevent exacerbation of the athlete’s symptoms and allow for continued recovery, “cognitive rest” is recommended. This rest may include a temporary leave of absence from school, shortening of the athlete’s school day, reduction of workloads in school, and allowance of more time for the athlete to complete assignments or take tests. Taking standardized tests while recovering from a concussion should be discouraged, because lower-than-expected test scores may occur.5,97 Test scores obtained while the athlete is recovering from concussion are likely not representative of true ability. Communication with school nurses, administrators, and teachers to be sure they understand these recommendations is imperative. 10
How can a school professional help a student recovering from a concussion?
A school professional can best support a student’s return to school and recovery by understanding possible concussion effects and providing the student with needed accommodations and support. Understanding concussion symptoms can help the student and members of the team identify individual needs of the student, monitor changes, and with proper permission, take action when necessary. This will help facilitate a full recovery and discourage students from minimizing the symptoms due to embarrassment, shame, or pressure to return to activities. 3
After reintegration into school, a student should be allowed adequate time to make up assignments, and the overall volume of make-up work should be reduced. Because students physically look well, it is not uncommon for teachers and other school officials to underestimate the difficulties that a student is experiencing and may downplay the need for cognitive rest. Education of teachers, counselors, and school administrators regarding the cognitive effects that a concussion may have on a student is important.10
How should schools respond to instructions from Health Care Providers?
“The contents of a note received from a physician may differ amongst providers. Some physicians will give detailed descriptions of academic accommodations suited to a particular student and his or her concussion, which can be easily followed by educators. Others may provide little or no details about the concussion. In the latter instance, educators should still help to determine if the student needs academic assistance, and if so, in what form.” 3
Note: Unlike Return to Play decisions, students don’t need to be “cleared” by a physician to return to school so doctor’s note and instructions may or may not be available in initial period of student’s return.
Who determines when the Student returns to school?
It is common for emergency departments to suggest the student not return to school until they have either been seen or been cleared by the healthcare provider. This recommendation often leads to a student being out of school for up to 1 or more week(s) while awaiting an appointment with a doctor, which may not be reasonable or necessary. It is also common for a medical professional to suggest the student not return to school until they are symptom-free. While it is true that an athlete must be 100% symptom-free before RTP, they do not need to be 100% symptom-free to RTL. The student may return to school when symptoms are tolerable and manageable, as long as the school makes appropriate adjustments for the student (the key point is that the school must understand concussions and necessary accommodations in order for the student who is still exhibiting symptoms to return to learn) 2
The school psychologist and/or the school nurse are the most skilled professionals at the school to help advise the parent and doctor when it is best to return the student to school. However, as the ultimate decision often/usually falls upon the parent, parents can utilize symptoms to determine when to safely return their student to school. 2
- If symptoms prevent the student from concentrating on mental activity for even up to 10 minutes at a time, rest is required. The student should be kept home from school on total bed rest with no (or very limited) television, video games, texting, reading, homework, or driving. Parents should consult a healthcare professional if this state lasts longer than a few days. 2
- If symptoms allow the student to concentrate on mental activity for up to 20 minutes at a time, parents should still consider keeping their student home from school, but total bed rest may not be necessary. Between periods of resting and napping, the student may engage in light mental activity, such as light reading or television, as long as these activities do not provoke symptoms. 2
Making the determination that an athlete is ready to begin implementing the graduated return to activity protocol is a medical decision. However, the school’s Concussion Management Team plays a critical role in deciding to return a student to activity—both academics and athletics. Communication among all members of the team is crucial. The school-based members of the Concussion Management Team will never clear an athlete to begin implementing the graduated return to activity protocol without the approval of the athlete’s health care provider. However, the Concussion Management Team has the authority to prevent a student from beginning activity if signs, symptoms, or behaviors of the concussion are still apparent in the academic setting or during physical activity.9
Once the student is ready to return to school, providing academic accommodations (e.g., extended time for tests, reduction of make-up work, rest breaks) can prevent exacerbation of symptoms and lead to a quicker and more successful recovery.
What is considered Best Practices for a School’s Concussion Team?
When a student returns to school following any injury, the school team’s responsibility is to (a) assess the needs, (b) design an intervention plan, (c) monitor the effectiveness of the plan, and (d) adjust and readjust until the student no longer has special needs resulting from the condition. Returning a student to school following a concussion is no different. 2
For schools who use RTI, Principles of Response to Intervention (RTI) as applied to TBI: Source: Colorado Concussion 8
- Thoroughly understand and assess the problem
- Apply a prescriptive intervention – early intervention is recommended
- Assess whether the intervention is having it’s desired outcome – progress monitoring
- Adjust: re-assess, attempt another intervention, progress-monitor: Adjust
This chart from Nationwidechildrens.org shows of what to do if increasing cognitive demand worsens symptoms. 6
Decision-Making flow chart 4
1 Wall Street Journal article, “Concussions on the Field, Repercussions in School, ” April 19,2013 http://online.wsj.com/article/SB10001424127887324108204579022770562136360.html
2 National Association of School Psychologists “Research-Based Practice – Return to Learning: Going Back to School Following a Concussion,” By Karen McAvoy http://www.nasponline.org/publications/cq/40/6/return-to-learning.aspx
Majerske, C. W., Mikalik, J .P., Ren, D., Collins, M. W., Cmiolo Reddy, C., Lovell, M. R.,& Wagner, A. K. (2008). Concussion in sports: Postconcussive activity levels, symptoms, and neurocognitive performance. Journal of Athletic Training, 43(3), 265–274.
3 CDC http://www.cdc.gov/concussion/pdf/TBI_Returning_to_School-a.pdf
4 National Children’s http://www.nationwidechildrens.org/concussions-in-the-classroom
5 From the American Academy of Pediatrics Clinical Report Sport-Related Concussion in Children and Adolescents http://pediatrics.aappublications.org/content/126/3/597.full
6 Nationwide Children’s Hospital, “An Educator’s Guide to Concussions in the Classroom” http://www.nationwidechildrens.org/concussions-in-the-classroom chart
7 Gerry Gioia’s Presentation for The Institute of Medicine https://docs.google.com/viewer?url=http%3A%2F%2Fwww.iom.edu%2F~%2Fmedia%2FFiles%2FActivity%2520Files%2FChildren%2FSports-Related-Concussion%2F4%2520Gioia%25202.pdf
8 Colorado Kids with Brain injuries https://docs.google.com/viewer?url=http%3A%2F%2Fcokidswithbraininjury.com%2Fckwbi%2Fwp-content%2Fuploads%2F2009%2F11%2FPrinciplesofRTI.pdf
9 Oregon Concussion Awareness and Management Program https://docs.google.com/viewer?url=http%3A%2F%2Fwww.ohsu.edu%2Fxd%2Foutreach%2Fprograms%2Fthinkfirst%2Fupload%2Focampguide.pdf
10 PEDIATRICS Vol. 126 No. 3, September 1, 2010 pp. 597 -615 (doi: 10.1542/peds.2010-2005) http://pediatrics.aappublications.org/content/126/3/597.full
SECTION FOUR: List of Resources for Parents, Teachers, Administrators and Free Training Videos
- Colorado’s REAP Program
- St. Louis Children’s Org Concussion Fact Sheet – references to RTL
For Schools to set up a Concussion Management Team
- COLORADO DEPARTMENT OF EDUCATION CONCUSSION MANAGEMENT GUIDELINES Authored by: Karen McAvoy, PsyD and Kristina Werther, LCSW
- BrainSTEPS PA’s State Concussion Program
- Gerry Gioia’s Presentation for The Institute of Medicine
- Colorado’s REAP Program
- Traumatic Brain Injury Networking Team: TBI Identification Protocal
- Colorado’s Kids with Brain injury: Principals of RTI
- PEDIATRIC ANNALS 41:9 | SEPTEMBER 2012: Importance of ‘Return-to-Learn’ in Pediatric and Adolescent Concussion Christina L. Master, MD; Gerard A. Gioia, PhD; John J. Leddy, MD; and Matthew F. Grady, MD
- Nationwide Children’s Org: An Educator’s Guide to Concussions in the Classroom
- McAvoy, K. (2009). REAP the benefits of good concussion management. Centennial, CO: Rocky Mountain Sports Medicine Institute Center for Concussion
- Colorado’s REAP Program
- Traumatic Brain Injury Networking Team: Educators and Professional Manual
- PA’s BrainSTEPS
- Nationwide Children’s Org: An Educator’s Guide to Concussions in the Classroom
For School Nurses
- CDC Nurse Fact Sheet
- CDC TBI School checklist
For Healthcare Providers
Training Videos available for free online
Video: BrainSTEPS Presents: Concussions in the Classroom – Return to Learning
Pennsylvania’sBrainSTEPS Brain Injury School Re-entry Program by Brenda Eagan Brown, Program Coordinator [email protected]
Video: Concussion In Iowa: Return to Learn Webinar