Concussion and Return to Learn

Concussion diagnoses have increased in the last decade. Administrators and instructors — not just doctors — are now expected to help students through the recovery process. Unfortunately, there is little medical consensus about returning students to the classroom after a concussion, a process called return to learn (RTL).

RTL is the process of resuming full academic activity following the diagnosis of a concussion and mild traumatic brain injury (TBI). Similar terminology includes Return to School, Cognitive Rest, and Cognitive Recovery.

RTL depends on many factors, including:

• Age
• Gender
• Severity of symptoms

This report highlights a five-step process for establishing a sound RTL program.

Develop a Concussion Management Plan

A concussion management plan is a written policy outlining an institution’s protocol for managing the risk of concussions, or mild TBI. These plans vary by institution.

In general, the plan for your K-12 school, college, or university should include:

• Training students and staff on concussion prevention and response
• How to immediately respond in the event of a concussion
• Your institution’s long-term concussion management plan from its occurrence and through recovery, including RTL protocols
• Training students and staff on RTL protocols

RTL Review Panel

A broad team should oversee creating and reviewing RTL protocols so they provide accurate medical information in a broad spectrum of circumstances.

Your panel should include:

• Faculty members who can provide practical advice on the best way to help students adjust in the classroom after a concussion or head injury
• Student services personnel who can provide insights into helping students resume normal classroom activities following a concussion. Staff members familiar with mental health conditions, learning disabilities, and difficult personal and family relationships are particularly helpful, as those populations may be prone to longer concussion recovery periods. Additionally, Student Services can advise on potential academic accommodations and modifications that may aid recovery.
• Health professionals who can advise on the latest medical protocols. Enlist the help of health care professionals with experience treating head injuries.
• Legal counsel familiar with athletic injuries and student health; they can advise on compliance efforts. All 50 states and the District of Columbia have passed concussion legislation.

Train Faculty and Staff

A basic understanding of concussion science can help faculty recognize the seriousness of these injuries.

Concussion training should include:

• Symptoms
• Typical academic problems
• Common misconceptions
• Potential accommodations

Symptoms

Symptoms of mild TBI and concussions are different for each person. Symptoms can affect how someone feels, thinks, acts, or sleeps.

Physical symptoms may include:

• Aversion to light or noise
• Dizziness or balance problems
• Fatigue and lack of energy
• Headaches
• Nausea or vomiting
• Vision problems

Symptoms related to thinking and memory may include:

• Attention or concentration problems
• Short- or long-term memory problems
• Trouble thinking clearly

Emotional symptoms may include:

• Anxiety
• Irritability
• Sadness
• Stronger emotions

Sleep symptoms may include:

• Sleeping less than usual
• Sleeping more than usual
• Trouble falling asleep

Typical Academic Problems

Possibly the most effective tool in alerting faculty and staff to the significance of concussions is information on the impact on academic activities. A survey on the academic effects of concussions asked students and parents what classroom problems students encountered after a concussion. The results showed that multiple symptoms and complications often accompany a head injury.

Highlights from this survey include:

What academic difficulties did the student suffer?

• Headaches interfering with schoolwork
• Problems paying attention
• Feeling too tired

What adverse academic effects did the student encounter?

• Increased time spent on homework
• Difficulty understanding material
• Difficulty studying

In what subjects did the student’s grades drop?

• Math
• Reading/language arts
• Science

Common Misconceptions

Some of the most common faculty and staff misconceptions include:

Use training to help staff and students better understand concussion prevention and dispel common misperceptions.

Academic Adjustments

It is safe to begin the RTL process before the student is completely free of concussion symptoms. Students are typically allowed to re-enter the classroom when they can tolerate 30 to 45 minutes of cognitive activity. Only a medical professional should grant students clearance to return to the classroom after a diagnosed concussion.

After a student is diagnosed with a concussion, the health care provider likely will write a note verifying the diagnosis to your institution. The prescribed treatment plan may offer RTL recommendations. It is common at this point for oversight to be passed to faculty and staff. Most students with concussions only have symptoms for a few days or weeks. If assessed and managed correctly, effects of this injury on a student’s classroom achievement are minimized.

Informal Adjustments

Educators make academic adjustments based on symptoms. In most instances, informal academic adjustments are sufficient since most students recover within a few weeks. Among the adjustments educators can help students employ in response to common symptoms:

Headache

• Allow breaks as needed in a quiet area.
• Identify aggravators and reduce exposure to them.

Difficulty concentrating or remembering

• Avoid testing or completion of major projects.
• Use preprinted notes.
• Employ human or information technology notetakers.

Sleep disturbances

• Allow for a late start or shortened school day to catch up on sleep.
• Allow rest breaks.

Dizziness

• Let the student put their head down if symptoms worsen.
• Take extra time between classes to avoid crowds.

Visual symptoms

• Reduce exposure to computers, smart boards, or videos.
• Limit screen brightness.
• Use audiobooks.
• Turn off fluorescent lights.
• Sit near the center of classroom activities.

Noise sensitivity

• Access a quiet space for lunch.
• Avoid typically loud classes like music and gym.
• Use earplugs.

Formal Adjustments

In rare instances, concussion symptoms are more severe than expected or linger beyond the usual recovery period. When concussion symptoms are particularly severe or extended, create a response team and implement formal adjustments.

A multidisciplinary response team creates a more comprehensive RTL plan when symptoms are more severe than normal, recovery is prolonged or atypical, or informal academic adjustments don’t stop a student from falling behind in school. Because every student’s personal history, academic record, and recovery speed is different, a multidisciplinary team should address the student’s unique needs.

A multidisciplinary RTL team’s goal is to balance the student’s academic demands and cognitive needs during recovery. Ideally, the team should include medical and nonmedical people from the following areas:

To minimize academic disruption and ensure the student doesn’t fall behind in the classroom, the team should model its RTL plan on a four-step strategy:

1. Assess the student’s symptoms and preexisting factors.
2. Design RTL strategies for observed symptoms.
3. Monitor student progress.
4. Adjust the RTL process as needed and begin the process again.

You may need written permission from students or parents to facilitate medical and educational information sharing among team members. Consult with legal counsel to deploy appropriate permission forms and waivers.

Formal academic adjustments typically address academic needs beyond three weeks. These include changes to standardized testing, extra time on work, or class schedule adjustments. Some students also may formalize accommodations in a plan under Section 504 of the Rehabilitation Act. K-12 public school students with extreme concussion symptoms such as chronic cognitive or emotional disabilities may require an Individualized Education Plan (IEP) under the Individuals with Disabilities Education Act (IDEA).

RTL team members’ expertise is crucial in drafting a comprehensive plan that fits the student’s needs and considers all resources available at your institution.

Additional Resources

Centers for Disease Control and Prevention: Concussion Fact Sheet for School Professionals