Clinical report: Students may need school break after concussion

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A comprehensive foundation for return to learning

This clinical report for the AAP is greatly needed, as the topic of return to learning (RTL) after concussion has been inadequately addressed. It is rare for school personnel and teachers to understand how concussion negatively impacts the injured student. This can cause a potential drop in grades and significant stress, which may delay recovery. Thankfully, many schools and athletic organizations have created plans to help injured athletes return to play, but now student-athletes will benefit from a complementary plan dedicated to returning to academics.

RTL is not a new topic for schools, as many have created plans for other conditions such as chronic illnesses or learning disorders. This report provides a framework that schools can use to create their own RTL plan.

The example put forth by Dr. Mark E. Halstead and his colleagues is a program that has been used successfully in several states. While the components of any good plan are similar, each school may tailor an RTL program to its unique academic needs.

Further research is still needed in order to help validate this program and to identify which academic adjustments are most beneficial to the concussed student-athlete.

Dr. Kevin D. Walter is associate professor of orthopedic surgery and pediatrics at the Medical College of Wisconsin in Milwaukee, and serves on the Institute of Medicine’s Committee on Sports-Related Concussions in Youth.



Patients who sustain a concussion need their physicians’ guidance in returning to school in a way that facilitates rather than hinders their recovery, and the American Academy of Pediatrics has issued a clinical report to help.

Most research on pediatric concussions has focused on returning the patient to sports or other physical activities, while data for managing the "return to learn" are sparse. Many published statements emphasize the need for "cognitive rest" – avoiding obvious potential cognitive stressors such as class work and homework – but fall short of identifying and dealing with the myriad other stimuli that can impede recovery or even worsen symptoms, reported Dr. Mark E. Halstead and his associates on the AAP Council on Sports Medicine and Fitness and the AAP Council on School Health (Pediatrics 2013;132:948-57).


The report notes that most concussions resolve within 3 weeks of the injury, so adjustments to the school environment can be made in the individual classroom setting without the need for a formalized written plan.

An estimated 1.7 million traumatic brain injuries occur each year, many of them concussions. "Given that students typically appear well physically after a concussion, it may be difficult for educators, school administrators, and peers to fully understand the extent of deficits experienced by a student with a concussion." This, in turn, might make school officials reluctant to accept that they must make adjustments for such students.

Pediatricians are in an excellent position to inform these educators, as well as the patients themselves and their families, of the symptoms that might develop and the strategies to prevent or minimize cognitive stress during recovery, said Dr. Halstead, an orthopedic surgeon and sports medicine specialist at Washington University in St. Louis and Children’s Hospital of St. Louis, and his associates. Dr. Halstead also presented the clinical report Oct. 27 at the annual meeting of the American Academy of Pediatrics in Orlando.

The clinical report notes that most concussions resolve within 3 weeks of the injury, so most adjustments to the school environment can be made in the individual classroom setting without the need for a formalized written plan such as a 504 plan or individualized education plan. However, students who require longer-term recovery need more formalized accommodations and modifications.

The report lists typical signs and symptoms of concussion, along with adjustments that teachers and administrators can make to help the child returning to school.

Headache is the most frequent symptom and can recur throughout recovery. School personnel should be made aware that fluorescent lighting, loud noises, and even simply concentrating on a task can elicit headache in these patients, so they should be allowed to take breaks in a quiet area when needed.

Dizziness and lightheadedness also are common and can be provoked by standing quickly, walking in a crowd, or even just viewing motion on a screen or in person. Students with concussion should be allowed to close their eyes or put their heads down on the desk if necessary, and should be permitted to avoid crowded hallways and to move slowly from one place to another.

Common visual symptoms include light sensitivity and blurred or double vision. Students should be allowed to wear a hat with a brim or sunglasses, to turn off or dim room lights, to dim video screens, or to forgo movies or slide presentations. They should be excused if they have trouble reading or writing, or even paying attention to visual tasks.

Sensitivity to noise means that students with concussion might need to be excused from the lunchroom, recess, shop classes, music (band or choir) classes, activities in a gymnasium, and any other excessively noisy location, and should be permitted to use earplugs, Dr. Halstead and his associates said.

Students with concussion also have trouble with concentrating and remembering. Allowances should be made for a student’s difficulty absorbing new material and focusing in the classroom; in particular, testing, especially standardized testing, might need to be postponed until after the student has recovered from the concussion.

Finally, concussions often cause sleep disturbances that can lead to excessive fatigue, tardiness, falling asleep in class, and excessive absences from class. Students might require a late start to the school day or a shortened school day to allow them to rest.

This AAP clinical report was endorsed by the American Medical Society for Sports Medicine, the Brain Injury Association of America, the Canadian Paediatric Society, the National Association of School Nurses, the National Association of School Psychologists, and the National Federation of State High School Associations.


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