Schooling concussion: Return to learn for the student athlete Alex M. Taylor, PsyD Neuropsychologist Brain Injury Center
Objectives Developing brain Response to injury Neurocognitive/ academic/ contextual considerations School based management framework
Developing brain Brain water content, cerebral blood volume, myelination, skull geometry, and suture elasticity are related to maturation
Developing brain Brain not fully developed until ~25 yrs Brain needs time & experience to mature Child s brain not well organized & undifferentiated
Developing brain Casey et al., 2005
Response to injury Plasticity Early insult may have impact on later development Greater secondary consequences Social/academic progress Capacities in process of development or not yet developed are particularly vulnerable to brain injury
Skills Skills Response to injury Established skills To be acquired skills Time Time Norm TBI Norm TBI
% of Group Learning difficulty following TBI 60% 50% 40% 30% 20% 10% 0% Prior to injury 6-month 12-month Extended Time Severe Moderate ORTHO n = 134 Taylor et al., 2003
Concussion
PCSS Natural history of concussion 80-90 % recover within 10-14 days Acute management risk of repeat injury & prolonged symptoms Typical Recovery Pre-Injury Pre-injury Day 1 Day 3 Day 14 3 Months months
Vulnerable neurocognitive skills Decreased NP functioning in concussed athletes Attention / concentration Working memory (online memory) New learning & memory storage / retrieval Speed of processing information Reaction time
Learning difficulty following concussion Symptom/ Problem Elementary Middle High School Headaches 53 73 71 Inattention 47 58 66 Fatigue 53 61 52 Comprehension 29 46 54 Difficulty studying 18 36 53 n = 349 Ransom et al. 2015
Case study: concussion
Percentile Case study: ImPACT data 100 90 80 70 60 50 40 30 20 10 0 Time 3/8/2011 1 Time 5/19/2011 2 Time 8/2/2011 3 Verbal Memory Visual Memory Processing Speed Reaction Time
PCSS Case Study: PCSS total symptom score 90 80 70 60 50 40 30 20 10 0 PCSS Faking it College admissions Summer job Playoffs SATs Dad s job Final exams Try outs Prom Day 1 Day 10 Day 21
Management guidelines Return to play Symptom free at rest Symptom free with exertion Graded RTP protocol Intact neurocognitive function Return to learn
Management Acute (injury-3 days) Post-acute (4-28 days ) Prolonged (>28 days)
Acute School Athletic Youth Family -Consult around when student should return to school -Remove from sports -Developmentally appropriate education, advice, and reassurance about mtbi -Ensure that caregivers can identify and act on neurological emergencies -Consider full rest with high initial symptom burden -Ensure that school is alerted to the injury and monitors for neurological deterioration -SLEEP -HYDRATION -Provide parent-focused education, advice, and reassurance about mtbi -Attend to caregiver anxiety Adapted from Kirkwood et al., 2008
Acute: reduce exertional effects Metabolic mismatch Exertional effects Classroom / school: demands on the brain Exacerbates metabolic mismatch and diverts resources necessary for cellular repair away from injured cells Treatment = sensible rest
Acute: overdosing cognitive rest? Utility of full rest > 3 days questionable (Silverberg & Iverson et al., 2012) Prolonged/ elevated symptoms in patients prescribed 5 days of rest following concussion (Thomas et al., 2014) Considerations Standard school year = 180 days 2-week absence = 5% school year or 22% qtr 37% of CPS students who missed 5-9 days of school did not graduate in 4yrs (Allensworth & Easton, 2007)
Acute: initial accommodations Rest breaks Quiet room Early dismissal Class exemptions (e.g., band) Sun glasses Physical Cognitive Reduce / adjust Class notes Assistive technology Alternative testing Audit / tutoring Emotional Sleep/Energy Support / guidance Safe signals Monitor mood Rest breaks Late arrival Early dismissal
Post-acute School Athletic Youth Family -Adjust accommodations to increase cognitive demand, as tolerated -Assess emotional toll restriction from sports may be having -Psychoeducational consultation as needed, including reassurance and reasonable symptom attributions -Recommend behavioral prescriptions as needed -Provide ongoing education and advice about symptoms -Emphasize preventing further injury while youth is still recovering
Prolonged School Athletic Youth Family -Coordinate school-based services among educators and healthcare personnel -504 plan (accommodations) -IEP (specialized instruction) -Ensure individualized cost benefit analysis conducted when considering return to play -Keep in mind persistent symptoms often at least partially reflect noninjury related factors -Consider cognitive behavioral therapy, focused on functional improvement -Reframe search for cure and help child develop more effective coping strategies -Explore post-injury family dynamics and consider family problemsolving therapy as needed -Consider non-injury related factors when developing educational plans Adapted from Kirkwood et al., 2008
Risks for prolonged recovery Acute markers Initial symptom score likely best predictor Prolonged LOC / amnesia Multiple collisions / contact prior to removal from play Premorbid considerations Prior concussion Psychological adjustment ADHD / LD Migraine Contextual factors
Risk: history of concussion Cumulative effect lowered threshold with additional injury increased vulnerability greater acute symptoms, including neurocognitive deficits potential for longer recovery times
Risk: psychological adjustment Psychological adjustment Pre-existing affective symptomatology potentially exacerbated Emotional or behavioral symptoms may be the direct result of the head injury OR a result of adjustment to injured status
Risk: neurodevelopmental disorder Attention deficit hyperactivity disorder Learning disability Already working with a vulnerable brain Resource allocation Compensatory strategies unavailable or take longer to be deployed
SUMMARY Children are not mini-adults Most children and adolescents recover from concussion within 1-3 weeks, but some take longer Initial treatment involves SENSIBLE rest Individualized, progressive return to learn practices minimize secondary consequence of missed school
Suggested readings Kirkwood, M. W., Yeates, K. O., Taylor, H. G., Randolph, C., McCrea, M., & Anderson, V. A. (2008). Management of pediatric mild traumatic brain injury: a neuropsychological review from injury through recovery. The Clinical Neuropsychologist, 22(5), 769 800. Lovell, M. R., & Fazio, V. (2008). Concussion management in the child and adolescent athlete. Curr Sports Med Rep, 7(1), 12 15. Master, C. L., Gioia, G. A., Leddy, J. J., & Grady, M. F. (2012). Importance of Return-to-Learn in Pediatric and Adolescent Concussion, (September), 1 6. McGrath, N. (2010). Supporting the student-athlete s return to the classroom after a sport-related concussion. Journal of Athletic Training, 45(5), 492 8. Meehan, W. P., Mannix, R. C., Stracciolini, A., Elbin, R. J., & Collins, M. W. (2013). Symptom severity predicts prolonged recovery after sport-related concussion, but age and amnesia do not. The Journal of Pediatrics, 163(3), 721 5. Popoli, D. M., Burns, T. G., Meehan, W. P., & Reisner, A. (2013). CHOA Concussion Consensus: Establishing a Uniform Policy for Academic Accommodations. Clinical Pediatrics. Sady, M., Vaughan, C., & Gioia, G. (2011). School and the concussed youth: recommendations for concussion education and management. Physical Medicine and Rehabilitation. 22(4), 1 17.
Thank you Brain Injury Center Boston Children s Hospital 617-355-2490 & Sports Concussion Clinic Division of Sports Medicine Boston Children s Hospital 857-218-5508