Every year in Canada alone, thousands of K-12 students sustain a concussion as a result of a fall, collision in their sport, or bike/auto accident. After a young person receives a concussion, it’s common for parents to worry when it is safe for their child to go back to school and other extra-curricular activities.
While many children will experience a straight forward recovery, some will experience lingering concussion symptoms that could result in future learning difficulties. It is always best to work with concussion management specialists who can help you navigate the recovery process for your child.
Within our clinical network, we focus on activity tolerance, rather than symptoms, as a gauge for when a student is cognitively ready to return to school. We specifically follow Berlin’s four-stage return process to make sure the child or adolescent can tolerate a certain amount of activity.
The Berlin Concussion Return to School Plan comes from the Concussion in Sport Group Consensus Statement [1]. After a concussion diagnosis, a student is required to follow a coordinated plan that includes a Return to Learning (RTL) plan and a Return to Physical Activity or Sport (RTS) plan.
Generally in this guideline there is a 24-48 hour rest period in which the young person can perform certain activities, provided they are well tolerated. Activities included in this initial period are things like card games and board games, short phone calls, and crafts.
The guidelines suggest not allowing children at this stage to watch television, play video games or use technology like a computer or smartphone. However, this may not be applicable to all children as treatment is based around symptom limited rest and symptom guided return. For us, it’s about making sure an activity is well tolerated and symptoms are not increasing.
After this initial phase a student can then proceed to Stage 1.
Generally speaking, children will perform light cognitive activities in this stage. Things like easy reading, doing puzzles and having some contact with friends. We also tell them to take breaks when they need.
Again, we tend to use the Berlin guide as a launch point and then individualize the treatment based on a patient’s tolerance and symptoms. Some may do fine at this stage getting on the computer for 20 – 30 minutes while others may find it worsens their symptoms.
It’s really a watch and see – then adjust scenario. If the patient does fine, we move them onto the next stage. If they need more time at this stage, that’s fine too.
During stage 2 we will gradually add more cognitive activities. For instance, we will introduce a bit of schoolwork that may be worked on in 30 minute increments. Students that did fine in stage 1 may look to add more tech time and those that weren’t able to handle getting on the computer can usually tolerate it well by this stage.
Usually at this stage most children aren’t yet ready to handle being back at school, even part time. We like to see them able to handle these new cognitive activities first, without any worsening of symptoms, before we move on.
This third stage is typically broken up into two sub-stages: stage 3a and 3b.
During stage 3a, students begin to re-enter the classroom for an initial time of 2 hours. Might be a little less depending on the child but usually not more than 2 hours to start. Again, we can’t recommend enough that all RTL plans be customized for each individual student. Some students may do fine with 2 hours while others may only be able to tolerate 1 hour. This is why we recommend working with concussion management practitioners so you can follow a personalized plan for your child.
We find at this stage it’s generally too early for children to be able to handle taking tests or exams, do homework or go on field trips. But, when they can handle being in class for 1-2 hours, without their symptoms worsening, then we move them onto the next phase.
Children will now be attending school for longer periods of time, usually 4-5 hours per day. We also find most can handle going home with some homework, much to their displeasure. And we also see most children able to handle classroom testing, though we do recommend some accommodations. We’ll get into accommodations in just a bit.
Like stage 3, stage 4 is also split into two sections: stage 4a and 4b.
During 4a the student will attend school for a full day with minimal accommodations or adaptations. We also typically allow them to take on a nearly normal workload, and increase homework. We allow some routine testing but limit it to one test per day with accommodations. So here, for instance, we might allow the student to take more time on a test.
During the second half of stage 4 we finally allow standardized tests and exams. We also begin to allow students to participate in non-sport extracurricular activities such drama club or the debate team, dependent on individual tolerance levels.
When you look at the stages we take children through, it becomes clear navigating these as a parent can be fairly challenging. And again, that’s because there is wiggle room, not every child will be the same and there is a need to customize the return to learning plan as much as you can to give your child the best chances of a speedy and full recovery.
Individualization allows concussion management specialists to establish two parameters for the student:
Parameter 1 – What is the goal we are trying to establish? In this case, it is returning to learning (AKA school).
Parameter 2 – What is the student’s current activity tolerance?
This second parameter is why a personalized recovery plan is so important, because no two children will have the exact same tolerance to activities. Ideally, you want to be able to make 100% certain that a student’s tolerance for “at-home” activities is equal to or greater than the goal you are working towards.
As an example, if the goal is to get the student to tolerate three hours of in-person classes, then we need to make sure they can tolerate three or more hours of listening to Youtube lectures at home while taking notes.
We can’t stress the need for individualized care enough when it comes to concussion recovery and return to learning environments. We have seen patients who are one, two and even three years out from their injury and still experiencing significant symptoms and poor activity tolerance. Whereas we also see patients who have little to no symptoms and can tolerate activity well one week after the initial injury.
So while we follow the Berlin stages, we leave room for individualization because this is how we achieve the best and safest outcomes for our patients.
You will have noticed that during the 4 stages we mentioned ‘accommodations’. What are these exactly?
Accommodations usually happen in the later stages when a student has returned to in-person classes for at least a couple of hours a day. These are interim measures, helping the child to move towards their overall goal in a graded manner. One common accommodation may be that he or she is allowed to take as many breaks as they need. Again, this should be a very individualized thing.
Some other common accommodations are:
What we have noticed is, those patients who have persistent concussion symptoms often need more support and more accommodations during their recovery process.
There are differing opinions on this, but in our opinion, too many accommodations can slow the recovery process down. For instance, we have had patients of all ages come in wearing sunglasses, a floppy hat and earplugs. While those things may help reduce symptoms initially, we never want a student to become dependent on accommodations. We want the person to never feel like a victim of their injury but always recognize their own healing and recovery.
So generally speaking, we’ll allow accommodations if we feel they will help the process. But we are hesitant to incorporate too many accommodations because patients can learn helplessness when we would rather them to identify with getting better.
There is obviously a big difference between the amount of cognitive thinking and the workload of a third grader and that of a university student. So, what can older students do to prepare themselves for going back to full-time classes?
If they are working with a concussion management specialist or an occupational therapist, they should work with them through some practice activities to see what exactly they can and cannot tolerate. Ideally you would have a couple of months to ramp up slowly to the expected workload.
If you don’t have that much time, you can take what time you do have and simulate the university environment at home as much as possible. See if you can get your hands on a textbook and practice reading through it, being sure to take breaks. You could set a timer for 20 minutes, then see how you feel and if symptoms remain at bay, move that up to reading for 30 minutes.
You could also find videos on Youtube about the specific topics you’ll be learning about and listen to them as if you were listening to a lecture. If listening for 20 minutes or so feels okay, see if you can add in some note taking.
Returning to school after concussion is definitely a slow and deliberate process. And because it can’t be said too many times, it is important to work with concussion management specialists that can create a customized recovery plan for your child. This will give them the best chance of getting back to school without any extended learning difficulties or persistent concussion symptoms.
In addition to creating an individualized recovery plan, concussion management specialists can also refer you to other specialists who may play a big role in your child’s recovery. For instance, occupational therapists may often refer patients to chiropractors and physiotherapists, because so many concussion symptoms are a result of lingering neck issues.
We have also found that children and adolescents can benefit from seeing a psychotherapist during their recovery. Healing from a concussion and being away from school and friends can be very challenging, especially for young children.
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