When Can A Child Return to Learning?

Patient Presentation
A 9-year-old female came to clinic in the morning with a headache that began 4 days previously after a fall at school onto a concrete surface. The patient had been pushed down backwards and hit the posterior part of her head. Witnesses and the patient denied loss of consciousness but the patient said she was slow to get up. Ice was applied and the patient returned to her class, but a headache made her go to the school office and her parents were called to take her home. Over the next 24 hours she remained alert and appropriate but continued to have a constant headache including at night. Over the next 2 days, which were the weekend, her headache improved but would return after playing with her brothers or when watching TV. The family came to clinic because the headaches had continued over the weekend and she had scheduled dance lessons in the evening. She denied any nausea, emesis, dizziness, tinnitus, photo- or phonophobia, clumsiness or difficulty doing activities, or sleep problems. She denied problems with reading or taking longer to think. She had not had a headache yet today. The past medical history was positive for a febrile seizure as a 16 month old. There were no other head injuries or neurological problems. The family history was positive for an aunt with depression.

The pertinent physical exam showed a well-appearing female with normal vital signs and growth parameters were in the 10-25%. Her neurological examination was normal as was the rest of her examination. The diagnosis of head trauma with minor concussion that was improving was made. Since the headaches still had occurred the evening before and the child hadn’t been up in the morning for long, the physician said it was difficult to tell how the child might do at school that day. However, he recommended to keep her out of school for the rest of the day and to not go to dance in the evening. Then he said that she could return to school, but the parents and school would need to be aware that her symptoms could return. He recommended they talk with the school today to make sure that the school could have her do quieter activities for shorter times and that if her symptoms returned that she could go to the office. He told the parents that light, noise and the concentration of doing school work could make the symptoms return. He went over symptoms for the parents to monitor and instructions about when to call the office. The physician did not hear back from the family and they returned to clinic about 10 days later for an unrelated problem. They said that she had one more headache on the day of presentation but none since. She had returned to school and dance without any problems. About the same time, the pediatrician learned that the American Academy of Pediatrics had released new guidelines on returning to learning after a concussion and then he reviewed them because of this patient.

Discussion
Head injury whether because of athletics or other trauma is a common problem in pediatrics. Fortunately most are benign because they are low impact that may not even result in edema or bruising. However, others cause concussion or traumatic brain injuries. There are an estimated 1.7 million traumatic brain injuries in the US yearly. Concussion can be very difficult to diagnose because there may not be external signs and the symptoms are highly subjective. For example, difficulties with concentration and thought processing speed are concepts that can be difficult for patients to understand, can be variable, and highly individualized. It can be even more difficult with younger children who really may not understand what a provider or parent is trying to ask them. There are symptoms scales available that can help with initial diagnosis and monitoring that were developed for concussion after athletic injury. These are the SCAT 3 for patients 13 years and older and the Child SCAT 3 for patients 5-12 years. The American Academy of Pediatrics Clinical Report also has symptom checklists available.

The school setting itself can provide challenges to student after a concussion. Schools are often noisy, visually stimulating, and require differentiated attention and behavioral standards which may be difficult for a concussed student to manage without adjustments being made. Fortunately most students with concussions recover within 1-3 weeks and adjustments in the classroom and other school settings can often be easily made by the regular education teachers and adminstrators. Examples would be frequent breaks, change of classroom seating, having lunch/recess in a quiet area, allowing extra time for assignment/assessment completion, giving prepared notes, etc.. For students with more prolonged symptoms, they would need more intensive evaluation and/or monitoring by concussion specialists, and in the school may or may not need a more formalized plan of adjustments or longer term accommodations or modifications in the school setting. For these students it is important to realize that these adjustments, accommodations and modifications need to carry over into the broad range of extra curricular activities also such as music, speech and debate, chess or language clubs, robotics or theatre.

Educational terminology that health care providers should be familiar with include:

• Adjustments are usually short term changes to the physical or educational environment and instruction. These do not require a formalized educational plan and are the normal changes that teachers and administrators make allowing for each individual student’s circumstances.
• Accommodations allow a student to complete the same tasks as their typical peers but with some variation in time, format, setting and/or presentation. The purpose is to provide the student with equal access to learning and an equal opportunity to show what he knows and what he can do. It does not change the instruction level, content or performance criteria.
• Modifications are alterations in instructional level, content or performance criteria (one or more of those elements) for a given assignment. These are change in what students are expected to learn, based on their individual abilities

Formalized educational plans fall under two major different types:

• IEP – individualized education plan which is often called special education. This comes from US Federal law under the Individuals with Disabilities Education Act or IDEA.
• 504 plan – this is a formalized plan for students who may not meet the specific eligibility for an IEP, but still need/require accommodations and modifications. This comes from a US Federal Law under the Americans with Disabilities Act and the Rehabilitation Act.
  Students with many chronic medical conditions have 504 plans such as patients with diabetes who need to check glucose levels at school.

For more information about formalized educational plans, click here.

Learning Point
The American Academy of Pediatrics also recommends a team approach to management of students with concussion including health care professionals, educators and the patient/family in helping the patient to return to learning and extracurricular activities. It also recommends that students who are able to tolerate 30-45 minutes of cognitive activity and stimulation can go to school with appropriate adjustments. Students who cannot tolerate this amount of cognitive activity or stimulation should remain home. The patient should be performing at baseline academically before extracurricular activities are allowed.

Many health care providers will recommend cognitive rest and then as symptoms and concentration improves light mental activities such as light reading, watching television, social interactions etc. can be started and increased in intensity and time as the patient tolerates. However, “…to date, there is no research documenting the benefits or harm of these methods in either the prolongation of symptoms or the ultimate outcome for the student following a concussion.”

Questions for Further Discussion
1. What are indications for head imaging in head trauma?
2. Who are the contacts in your local school system who could help to manage educational adjustments for students with concussions?

Related Cases

Disease: Concussion | Developmental Disabilities | School Health

Symptom/Presentation: Headaches

Specialty: Adolescent Medicine | Emergency Medicine | General Pediatrics | Neurology / Neurosurgery | School

Age: School Ager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Concussion, Developmental Disabilities, and School Health.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Consensus statement, SCAT3. Br J Sports Med 2013;47:5 259.

Consensus statement, Child SCAT3, Br J Sports Med 2013;47:5 263.

Halstead ME, Devore CD, Carl R, Lee M, Logan K, Council on Sports Medicine and Fitness and Council on School Health. Returning to Learning Following a Concussion. American Academy of Pediatrics.
Available from the Internet at http://pediatrics.aappublications.org/content/early/2013/10/23/peds.2013-2867.abstract (rev. 10/27/13, cited 11/5/13).

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