Draft
11-7-16
For Review
Only—
Concussion
Module
Development
Concussion in
Children &
Youth:
Providing
Supports in the
School Setting
2
Traumatic Brain Injury
 There
are approximately 1.5 million
Traumatic Brain Injuries sustained in
the U.S. annually
 1.1
million are treated and released
from an emergency department
 An unknown number don’t seek
medical care
DRAFT: CONCUSSION MODULE NOV 2016
3
Concussions…


are the most common type of
brain injury
are often not detected by common
neuro-imaging tools
 may
or may not involve a loss of
consciousness
:
DRAFT: CONCUSSION MODULE NOV 2016
4
What Causes a Concussion?
 Rapid
movement of the brain inside the
skull, resulting in tissue becoming bruised,
torn and swollen
 Secondary
damage can result from
shearing and tearing of neurons at a
microscopic level , and chemical
changes
(Insert interactive graphic here)
DRAFT: CONCUSSION MODULE NOV 2016
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Most commonly caused by:
 Car
crash
 Fall
 Bicycle
crash
 Sports Injury
 Physical Assault
 Being shaken
DRAFT: CONCUSSION MODULE NOV 2016
6
Concussion Signs & Symptoms
Headache
Dizziness
Confusion
Nausea/vomiting
Decreased energy
Irritability
Poor balance
Sleep problems
DRAFT: CONCUSSION MODULE NOV 2016
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Concussion Signs & Symptoms
Sensitivity to light
Sensitivity to noise
Lethargy
Slow response time
Poor concentration
Tinnitus
Sleep disturbance
Anxiety
Poor memory
Blurred or double
vision
 Irritability
DRAFT: CONCUSSION MODULE NOV 2016
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Signs & Symptoms…



Can be immediate or delayed (up to 24
to 48 hours after injury)
May go unnoticed until certain demands
are placed (i.e. reading in class)
Often resolve over 10-14 days; however,
recovery can be prolonged (weeks to
months)
DRAFT: CONCUSSION MODULE NOV 2016
9
Recovery
 Severity
of the impact doesn’t always
correlate with the severity of symptoms
 Somatic
symptoms often recover first, with
cognitive improvement occurring more
slowly
 Delay
in recognizing or experiencing
symptoms can result in child returning to
play or school immediately after injury...
followed by abrupt increase in symptoms
DRAFT: CONCUSSION MODULE NOV 2016
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Outcomes
Outcomes can vary greatly,
depending on gender, age,
location of impact, & force
DRAFT: CONCUSSION MODULE NOV 2016
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Risk Factors for Persistent
Symptoms Following Concussion
Preinjury
A
complications/diagnoses
history of past concussions
DRAFT: CONCUSSION MODULE NOV 2016
12
Second Impact
Syndrome
● Second concussion sustained prior to
complete healing of the initial
concussion
● The healing brain is more vulnerable
● Outcomes are typically more severe
than the initial injury
● Can result in coma or death
DRAFT: CONCUSSION MODULE NOV 2016
13
Acute Identification
& Care Following Injury
A student exhibiting symptoms at
school should immediately be seen by
the school nurse/health services staff
Parent/guardian contacted
Student should be observed for
symptoms and determine if emergency
care is needed

DRAFT: CONCUSSION MODULE NOV 2016
CDC Concussion
Signs & Symptoms
Checklist
Evaluates:
●
●
●
●
Observed signs
Physical Symptoms
Cognitive Symptoms
Emotional Symptoms
https://stacks.cdc.gov/view/cdc/12353/
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15
Initial Concussion Care
Remove immediately from physical & cognitive
activity
Assess for concussion symptoms
Assess for other injuries
Gather injury information and document
Contact parent/guardian
Reevaluate after a period of rest and determine
next steps
WHEN IN DOUBT - SIT
THEM
OUT!
DRAFT:
CONCUSSION
MODULE NOV 2016
16
Is Emergency Care Needed?
If student is showing the following signs or their
condition worsens, call 911, and follow school
protocl for notifying parent/guardian and
school administrator
 Loss of consciousness (even brief)
 Slurred speech
 Vomiting
 Seizures
DRAFT: CONCUSSION
MODULE NOV 2016
 Can’t recognize people
or places
17
Need for Emergency Care,
Continued
- Excessive drowsiness
- Weakness or numbness in arms and
legs
- One pupil larger than the other
- Increasing agitation, confusion
- Severe, worsening headache that
does not resolve with rest
DRAFT: CONCUSSION MODULE NOV 2016
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Non-Urgent
Concussion Care




Period of rest in health office
Check on student every 15 min or
more often as needed
Ice pack to head
Elevate head if able
DRAFT: CONCUSSION MODULE NOV 2016
19
Non-Urgent Concussion Care,
Continued

Limit brain stimulation
No electronics or cell
phone
Darkened room if possible
Quiet area



DRAFT: CONCUSSION MODULE NOV 2016
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Non-Urgent Concussion Care,
Continued




Give acetaminophen if needed as
per school guidelines
Keep hydrated
Do not return to class if
symptomatic after period of rest
May need to leave school if
symptoms do not improve
DRAFT: CONCUSSION MODULE NOV 2016
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Non-Urgent Concussion Care,
Continued


Continue documentation
Inform parent/guardian of
potential need for medical
evaluation and clearance to
resume physical activities at
school
DRAFT: CONCUSSION MODULE NOV 2016
22
Back to Class When SymptomFree




Communicate with teacher(s)
Tell student to return to health office if
symptoms return
Reminder to sit out of physical education
class, recess and any sport activities for
the remainder of the day
Recommend nurse/teacher check-in
with student the next day and as needed
DRAFT: CONCUSSION MODULE NOV 2016
23
Return to LEARN Following A
Concussion
DRAFT: CONCUSSION MODULE NOV 2016
24
Return to Learn Overview
1. Rest & Planning
2. Return gradually with support
3. Slowly work up to full time and full
workload
4. Return to physical activities
DRAFT: CONCUSSION MODULE NOV 2016
25
After a Concussion
Has Occurred





Provide quiet, restful environment for the
student (usually the student’s home)
Gather information from family, including
medical documentation if available
Notify school personnel – Concussion Care
Team
Identify a plan for a return to school
Disseminate information to teachers and staff
DRAFT: CONCUSSION MODULE NOV 2016
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Role of Concussion Care Team
Identify points of contact within your school for:
Communicating with family, external
providers and school team
Monitoring and documenting symptoms
Implementing and monitoring academic
supports



DRAFT: CONCUSSION MODULE NOV 2016
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Don’t Forget to….


Identify student’s contact
person in school
involve the student & discuss
their role
DRAFT: CONCUSSION MODULE NOV 2016
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A Concussion Plan

Goal: To get the student back to previous
activities, supported with proper
accommodations to manage symptoms




When to Return
School contacts
Specific accommodations
Timelines
DRAFT: CONCUSSION MODULE NOV 2016
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Sample Concussion Plan
DRAFT: CONCUSSION MODULE NOV 2016
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Other Considerations
 History
of past concussions?
 Currently
taking prescribed medications?
 Avoid
all contact sports/activities until
symptoms completely resolve; consider
no involvement in contact sports; always
protect head
DRAFT: CONCUSSION MODULE NOV 2016
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When to Return to School


Extended time away from school (or
home-based school services) after a
concussion is rarely recommended
Factors to consider for return timeline:


Symptom severity
Other injuries
DRAFT: CONCUSSION MODULE NOV 2016
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When to Return to School,
Continued



How much school has already
been missed
Home environment
Return to school may include
partial days as tolerated
DRAFT: CONCUSSION MODULE NOV 2016
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Other Considerations
 Talk
with child/teen about importance of
recognizing/sharing symptoms
 Encourage
a healthy food plan and
adequate hydration
DRAFT: CONCUSSION MODULE NOV 2016
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If concerns remain……
 Work
with primary care physician or
specialist to identify treatment options
 Review modified school day plan
 Closely monitor student’s behavior,
energy level, etc. once they have
returned
 Identify someone the student can ‘check
in’ with (school nurse, counselor, teacher)
DRAFT: CONCUSSION MODULE NOV 2016
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Upon Return
to School
 Set
up a meeting with parent/guardian,
student, and concussion team; include
educational specialists as needed
 Identify
primary staff person in school who
will serve as communication link with family
 Share
educational information & resources
on concussion
DRAFT: CONCUSSION MODULE NOV 2016
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Temporary
Accommodations
 May
be needed for 6 to 8 weeks or more
 Accommodations
should be agreed
upon by parents, school staff, and student
 Most
students return to full cognitive
functioning within 3 months of injury
DRAFT: CONCUSSION MODULE NOV 2016
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Types of
Accommodations
Reduce Physical Demands





Shorten school day
Offer frequent breaks throughout day
Provide a quiet environment to rest
Build study hall(s) into schedule
Consider no extra-curricular activities
DRAFT: CONCUSSION MODULE NOV 2016
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Types of
Accommodations
Reduce Cognitive Demands
 Shorten
school day
 Eliminate/reduce homework
 Eliminate, delay or allow untimed
quizzes/tests
DRAFT: CONCUSSION MODULE NOV 2016
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Types of
Accommodations
Reduce Cognitive Demands, continued
 Reduce
time spent reading, writing or
on computer
 Help student refocus as needed
 Provide visual cues to assist in recall
DRAFT: CONCUSSION MODULE NOV 2016
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Types of
Accommodations
Reduce Cognitive Demands, continued
 Provide
more time to complete assignments
 Reduce assignment and homework load
 Assist with organizing materials as needed
 Modify test format or setting
DRAFT: CONCUSSION MODULE NOV 2016
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Types of
Accommodations
Reduce Cognitive Demands, continued
 Drop
or delay some classes
 Consider short term alternate grading system
DRAFT: CONCUSSION MODULE NOV 2016
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Types of
Accommodations
Reduce Sensory Demands
 Consider
alternate hallway passing times
 No physical education classes or playground
recess
 Consider no music class or band
 Consider alternative to school bus transportation
DRAFT: CONCUSSION MODULE NOV 2016
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Types of
Accommodations
Social/Emotional Support
 Show
tolerance of emotional
outbursts, irritability, anger
 Help student understand why these
changes have occurred
DRAFT: CONCUSSION MODULE NOV 2016
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Types of
Accommodations
Social/Emotional Support, continued
 Consider
offering an in-service to
student’s peers
 Offer support and encouragement;
help student focus on positive
changes
DRAFT: CONCUSSION MODULE NOV 2016
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Share/Discuss Concussion Plan
with Others




Student/Family
Academic Team (teachers, school nurse,
guidance counselor, administrators,
social worker, P.E. teacher)
Athletic Team (coach, athletic trainer)
Medical Team (primary care provider or
concussion specialist, rehab team,
psychology)
DRAFT: CONCUSSION MODULE NOV 2016
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Challenges in Recovery





“But they look fine…”
Symptoms - variable & individual
Information from medical providers
Communication with family
Pre-injury factors
DRAFT: CONCUSSION MODULE NOV 2016
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Keep in Mind…
No one plan fits all; if you
have seen one concussion,
you have only seen one
concussion!
DRAFT: CONCUSSION MODULE NOV 2016
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Keep in Mind…
Accommodations may be needed for days
or months
Should be agreed upon by parents, school
staff, medical providers, and student
Monitor progress and document
As symptoms decrease, supports can be
removed gradually
No return to activity until cleared
DRAFT: CONCUSSION MODULE NOV 2016
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As symptoms decrease, the
extra help and supports can
be removed gradually.
But if symptoms persist…
DRAFT: CONCUSSION MODULE NOV 2016
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Spectrum of
Supports:
Overlapping
Domains
In the School
Setting
DRAFT: CONCUSSION MODULE NOV 2016
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Other Options for Support:
504 Plan
 Federal
anti-discrimination law
 Protects
rights of individuals with
disabilities in programs/activities
that received federal financial
assistance from US Dept. of
Education
DRAFT: CONCUSSION MODULE NOV 2016
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504 Plan
A
legal document that requires
signature of all participants
Must have a documented disability
Substantially limits a major life
activity
504 plan identifies
accommodations and services
DRAFT: CONCUSSION MODULE NOV 2016
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504 Plan
Provides accommodations to:
 Physical
environment
 School schedule
 Presentation of materials
 Alternative materials/assistive
technology, etc.
DRAFT: CONCUSSION MODULE NOV 2016
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When to Consider Eligibility for
a 504 Plan




When symptoms don’t resolve after 4-6
weeks, or worsen with increased activity
When new symptoms occur over time
When a concussion plan doesn’t provide
enough support
When there’s increased need for
documentation
DRAFT: CONCUSSION MODULE NOV 2016
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Other Options for Support:
IDEA (Special Education)
 Special
Education services should be
considered when educational needs are
chronic, long term
 Evaluation can be requested by educator
or parent
 Must have documentation of medical
diagnosis, and meet state TBI criteria
DRAFT: CONCUSSION MODULE NOV 2016
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IDEA: TBI Criteria
Caused by ‘external physical force’
Total or partial functional disability and/or
psycho-social impairment
Adversely affects educational performance
Documentation of medical diagnosis
Consistent with Federal definition
DRAFT: CONCUSSION MODULE NOV 2016
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Return to PLAY Following A
Concussion
DRAFT: CONCUSSION MODULE NOV 2016
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IEP Services & Supports
 Student
goals & objectives
 Accommodations and
Modifications
 List of team members, including TBI
specialist*
Special education services and
providers
DRAFT: CONCUSSION MODULE NOV 2016
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Return to PLAY
Returning to prior level of physical
activity including gym, recess,
recreational activities, and athletics
A provider-directed, stepwise increase in
physical activity designed to ensure a
safe, symptom-free return to sports or
recreational activities
DRAFT: CONCUSSION MODULE NOV 2016
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Minnesota State High School
League Protocol for Return to
Play:
http://www.mshsl.org/mshsl/spor
ts/ConcussionProtocol.pdf
DRAFT: CONCUSSION MODULE NOV 2016
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Return to Play Procedure
● Clearance must be in writing from
physician
A parent cannot authorize return to play for
his or her child
Activity should be stopped if symptoms return
at any point
● Student must be symptom free for 24 hours
before restarting return to play protocol
DRAFT: CONCUSSION MODULE NOV 2016
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Return to Play:
Collaboration
● Communication is key
● Assure that everyone understands school
protocol
● Identify specific roles of staff when
identifying and providing support to
students with concussion
Note: Not all members need to be involved
DRAFT: CONCUSSION MODULE NOV 2016
CDC: ACE Care Plan
Acute Concussion
Evaluation (ACE): School
Version
Returning to School
● ADL’s
● Academic accommodations
● Return to sports and activities
http://www.cdc.gov/headsup/providers
/discharge-materials.html
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CDC Resources
 Heads
Up to Schools: Know Your
Concussion ABCs (fact sheets for parents,
school nurses, and
teachers/counselors/school professionals)
 Heads
Up: Concussion in Youth Sports
(Information packet for coaches)
www.cdc.gov/concussion
DRAFT: CONCUSSION MODULE NOV 2016
CDC Fact Sheets: School Nurses, Parents,
Educators, Coaches
Heads Up to Schools:
Know Your Concussion ABCs
A—Assess the situation
B—Be alert for signs and symptoms
C—Contact a healthcare professional
www.cdc.gov/concussion
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