Hardly any aspect of life could be more impacted by a concussion than school. Brain function and the ability to learn, of course, are intimately linked. If your school-aged child has suffered a concussion, you may be perplexed about what to do next.
But don’t worry. In what follows, we will look at a step-by-step protocol based on the latest available concussion research to help your child return to school safely after a concussion.
Before discussing practical steps toward your child’s total return to school, it is important to lay some preliminary groundwork. Your understanding of how to recover from a concussion begins with understanding what a concussion is. So, let’s start there.
A concussion (or mild traumatic brain injury; mTBI) is an injury that results from a biomechanical impact to the head or the body, leading to acceleration-deceleration forces that functionally disrupt the brain. Concussion does not damage the structure of your brain, which means that after the injury, there are no perceivable changes to the brain’s tissues.
For this reason, x-rays, CT scans, blood tests, and the like do not help diagnose a concussion. Imaging and blood tests serve only one purpose in the case of head injuries: to rule out something more severe than a concussion like a brain bleed.
Instead, a concussion is better understood as a functional injury. Why? Because rather than changing how the brain looks, it changes how it works. Since the brain is the main central processing unit of the body, an injury to the brain can affect various bodily systems. This means your concussion symptoms may result from a variety of temporary disorders, including dysfunction of the nervous system, endocrine (hormone) system, visual system, and/or gastrointestinal system.
There is often a psychological component to a concussion as well. To be sure, the loss of everyday function at home, work, or school, not to mention the discomfort of symptoms, can have a significant impact on one’s mental health.
All of this points toward the need for a safe and appropriate step-by-step plan for returning to school—which is precisely what we’re here to provide you with!
It has become increasingly clear that prolonged absence from school after a concussion is associated with a more significant symptom burden over time and does not speed up recovery time. This means, maybe surprisingly, that your child should return to school before symptoms have entirely resolved. (Your clinician is there to help you with these decisions).
How soon should your child go back?
It is recommended that students return to school as soon as a couple of days after sustaining a concussion. Recent studies (like this one) have confirmed that students who return to school, even for partial days, within 2-3 days following a concussion had a lower symptom burden two weeks later. Since symptoms usually reach their peak 3-5 days after a concussion, a return to studies should begin right around the time that symptoms start to drop.
Now, the return-to-school process is gradual. After a day or two of light cognitive activity and mild-intensity exercise at home, your child’s initial return to school will be for a partial day only, and school activities will be modified appropriately. Over time, as you proceed through the stages with your child (described below), activity restrictions will be reduced, and full-day attendance at school will be introduced.
Because your child will likely still be symptomatic and also because his/her brain will still be healing when he/she returns to school, it is essential to have realistic expectations. So next, let’s look at potential temporary barriers your child might face throughout the return-to-school process.
It is possible—even expected—that, upon first returning to school after a concussion, symptoms may increase in severity. This could be caused by increased cognitive demand, sensory stimulation, and/or physical exertion.
This temporary symptom increase will not harm your child, but an appropriate response is required. This could mean taking breaks from aggravating activities while at school or making further modifications like, say, in the case of light sensitivity, working in a darker space.
As your child recovers from a concussion, his/her brain will likely tire more quickly than usual. This means that some tasks may take longer than before the injury. You may also find that your child experiences:
Your child may also struggle to keep up with conversations and follow along when multiple people speak simultaneously.
The bottom line is to be patient and reassure your child that these challenges will decrease and eventually disappear.
Physical activity can elicit symptoms like headaches, dizziness, or nausea, depending on the level of exertion. Though light physical activity is vital from “day one” of concussion recovery, things like recess and gym class should be eliminated initially until returning to higher-risk, higher-intensity environments is safe.
Your child may also experience more fatigue with exercise than was typical before his/her head injury.
Again, getting adequate exercise is one of the most critical aspects of recovery from concussion. Indeed, “exercise is medicine” for concussion. Nonetheless, to avoid unnecessary delays in your recovery, it is vital that your child follows the specific guidelines provided below and, above all, that he/she recognizes the body’s changing tolerance to physical activity at the various stages of healing.
Headaches hurt.
They can also interfere with cognitive performance and make social interactions more difficult. But like all of the other symptoms of concussion, the headaches experienced as a result of your concussion are treatable. This is why it is essential that you find a clinician with the appropriate training to identify and treat the underlying cause(s) of your child’s headaches.
A concussion is not like most injuries in that it is, to a large degree, invisible.
Whereas an injury like a broken leg is tough to hide during recovery, there are usually few, if any, visible signs of concussion. And while the symptoms of a concussion can be at least equal to, if not more, intense and complex than the symptoms of other injuries, they often go unperceived by others. As such, people at school may have a hard time empathizing with someone who is recovering from a head injury.
You may request a letter from your child’s clinician to the school administrator or teacher to communicate the nature of the injury. That letter may also explain the return-to-school protocol you will be following.
Having well-informed teachers means having powerful advocates by your child’s side as he/she faces the post-concussion challenges of returning to school. Being at school, even in the early stages of recovery, and having the support of your friends can be a powerful aid to mental health and overall recovery.
You must also check in with your child, asking how they are feeling, inquiring about their frustrations and victories of the day, and giving them consistent positive affirmation and reassurance.
The majority of school-aged children who seek evaluation and treatment for their concussions within the first few days following injury will fully recover within 4 weeks.
Those who wait for a prolonged period usually have a significantly longer road to recovery, sometimes taking months instead of weeks. It cannot be stressed strongly enough: earlier evaluation by a trained clinician means faster recovery! But better late than never.
What will treatment include? Because concussion symptoms can have diverse physiological and psychological causes, a concussion management plan should consist of things like manual therapy, cardiovascular exercise, a healthy diet, adequate sleep, and established steps for returning to school and work.
Care plans may also include vestibular rehabilitation for symptoms related to inner ear dysfunction and vision rehabilitation for eye dysfunction when indicated. Your clinician will determine which treatments suit your child best and accompany you through the recovery process.
What follows are the stages of a sound “return to learn” protocol. Remember: early clinical evaluation means faster recovery. Once you have done this, here are the steps you should follow:
This first stage happens at home.
It was once thought that a relatively long period of “absolute rest” was beneficial to recovery from concussion. Over time that has proven to be false. Prolonged absolute rest is now known to be detrimental to recovery!
In this initial stage, your child’s physical and cognitive activity levels should be low enough that symptoms are not being increased throughout the day.
Your child may feel generally fatigued and have low energy but should not be permitted to sleep all day! Naps are okay and sleep is a critical part of the recovery process, but it is not more important than symptom-limited cognitive and physical activity.
The golden rule of stage 1 is this: stay as active as possible without increasing your symptoms.
Your child may proceed to Stage 2 after 24 hours without an increase in symptoms.
In this stage your child can begin to do school-related activities like homework and other home-based assignments. Again, the goal is to complete these activities (i.e., cognitive activities) while keeping symptoms to a minimum. If symptoms increase during these kinds of activities, your child should take a break and try again later in the day.
Your child should also increase physical activity, choosing low-risk ways of getting cardiovascular exercise without significantly increasing symptoms. Your clinician may subject your child to a specialized, in-clinic treadmill test, especially if your child is an athlete, to help determine what level of cardiovascular exertion will be appropriate at this stage of recovery.
Once your child can tolerate 45 minutes to one hour of light cognitive activity with minimal increase in symptoms, it will be be time to proceed to Stage 3.
Your child may now return to school for a half day but his/her activities should be restricted. Restrictions include no tests, no gym, and no recess. If any homework is assigned, your teachers should provide loose, reasonable deadlines for completion.
Tests should not be administered until your child has returned to full cognitive capacity. The prohibition on gym and recess is intended to prevent a second impact in higher risk environments.
Even if this half day of school is completed without any exacerbation of symptoms, your child should still go home for the remainder of the day. If a significant symptom increase is experienced, return to Stage 2.
Once a half day at school is completed without an increase in symptoms, your child may move on to Stage 4.
At this late stage of the return-to-school protocol, your child should be able to complete a full school day without experiencing any significant increase in symptoms. The same modifications as Step 3 remain in place.
Once a full day at school without an increase of symptoms can be completed, restrictions may be lifted gradually until a full day of school without an increase in symptoms can be completed.
Once your child has reached this final stage, it may be time for full medical discharge from concussion care. Thus, once an asymptomatic full day of studies is achieved, it is important to see the clinician for final clearance for a full return to cognitive and physical activity.
If your child is also an athlete, it is important to understand that the successful completion of the return-to-learn protocol does not mean it is time for a full return to sport. Athletes will undergo a simultaneous return-to-play process, and may not progress at the same rate through the stages of the return-to-play protocol.
Returning to school after a concussion requires careful monitoring and gradual steps to ensure a successful recovery. Start by finding a good clinician who can guide this process.
By following these stages of the “return-to-learn” protocol, your child can return to studies without risking further injury or setbacks in their healing process. It is important to remember that each individual may progress through these stages at different rates, and it is essential for patients to listen to their bodies and communicate with their medical provider throughout the process. With patience and proper care, students can safely return to school and resume their normal activities with minimal impact on their daily lives. So if your child has suffered from a concussion, don’t rush them back into full-time studies right away—take the necessary precautions for a successful recovery.
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