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Concussion Awareness:

Getting School Psychologists Into the Game

By Susan C. Davies

In an effort to stay current with teen culture, I recently watched the latest Jackass movie. All I could think throughout the film was, "Wow, these guys must’ve had a lot of concussions." And while I admit to laughing at the daredevil antics from time to time, a concussion is a serious injury—a mild traumatic brain injury (TBI)—that induces physiological disruption of brain function.

A concussion is caused by a bump, blow, or jolt to the head or body. The sudden movement causes stretching and tearing of brain cells; cells become damaged and chemical changes occur within the brain. Although most individuals who have sustained a concussion recover completely, some individuals can have symptoms that last for weeks or longer (Kirkwood et al., 2008). Concussions can lead to cognitive, academic, behavioral, and emotional problems that last beyond that initial period of seeming "dazed." These effects are compounded when individuals sustain a second concussion before they have been given opportunity to recover from a first (i.e., "second impact syndrome"). A repeat concussion before the brain has recovered from the first can slow recovery, increase the likelihood of long–term problems, and—in rare cases—result in swelling of the brain, permanent brain damage, and even death (Collins et al., 2002; Guskiewicz et al., 2003).

Concussions have been called a "silent epidemic" because symptoms can be subtle and covert (Langolis, Rutland–Brown,& Thomas, 2006). However, several high–profile concussion cases involving professional athletes have turned media attention to concussions. Those stories, coupled with stories on the more than 300,000 troops who have sustained concussions during recent combat (Hoge, Goldberg,& Castro, 2009), have helped to increase our awareness of the potential impact of concussions. However, in the sports world, it is not just NFL football players sustaining concussions: It is school–age athletes knocking heads in soccer, knocking helmets in hockey, getting slammed to the mat in wrestling, and falling during stunts in cheerleading. We must also understand that concussions affecting school children go beyond sports: Car accidents, fights, falls, abuse, and collisions during recreational play can all lead to concussions. In fact, 80% to 90% of all traumatic brain injuries are classified as mild and only 20% of those are sports–related (Lewandowski & Reiger, 2009). Thus, although concussions involving adult athletes have received a great deal of press, young children and adolescents are more likely to get a concussion, to get them off the playing field, and to take longer to recover than adults (Buzzini & Guskiewicz, 2006; Centers for Disease Control, 2007; Langlois, Rutland–Brown, & Wald, 2006).

According to the Centers for Disease Control and Prevention (CDCs; 2007), an estimated 1.7 million people obtain a TBI every year. Of these 1.7 million people, 52,000 result in death, 275,000 result in hospitalizations, and 1,365,000 are accounted for through emergency room visits. Seventy–five percent of these TBIs are concussions or other mild TBIs. Within these findings, children between the ages of birth and 14 years account for almost half a million of the emergency room visits for TBIs. In every age group, males have a higher prevalence rate, with boys ages birth to 4 years having the highest prevalence rates of TBI–related emergency department visits, hospitalizations, and deaths. Additionally, the CDC estimates that U.S. emergency rooms treat 135,000 sports and recreation–related TBIs in youth ages 5–18 (CDC, 2010a). Langlois, Rutland–Brown, & Thomas (2006) suggest the number of concussions is actually much higher—up to 3.8 million children and adults—largely because concussions are often underreported and untreated.

Many people who sustain concussions appear to recover fully in 1 or 2 weeks (Yeates & Taylor, 2005). However, adolescents’ brains can take several weeks longer than adults’ brains to heal following a concussion (CDC, 2010b). Those at risk for slower recovery include individuals with prior brain illness or injury, learning disabilities, or psychiatric disorders. Thus, school psychologists must be aware of concussion signs and symptoms, educational implications, and assessment strategies. We are also in an excellent position to initiate and sustain systems–level change by promoting prevention and intervention efforts.

Signs and Symptoms

Unlike a cut or broken bone, concussions are not always easily detected. They are a problem of function, not structure; therefore, MRIs or CAT scans generally appear normal when an individual has sustained a concussion. Further, 90% of concussions do not result in full loss of consciousness (Collins et al., 2003; McGrath, 2010). Immediately after sustaining a concussion, a child might appear dazed or stunned, confused, uncoordinated, and have difficulty recalling events prior to or after the injury.

The CDC (www.cdc.gov/concussion) describe four categories of concussion symptoms: thinking/remembering (difficulty thinking clearly, feeling slowed down, difficulty concentrating, and difficulty remembering new information), physical (headache, fuzzy or blurred vision, nausea or vomiting, dizziness, sensitivity to noise or light, balance problems, feeling tired/having no energy), emotional/mood (irritability; sadness; more emotionality, nervousness, or anxiety), and sleep (sleeping more than usual, sleeping less than usual, or trouble falling asleep). Certain activities such as exercising or activities that require a lot of concentration (studying, computer work, video games) might cause concussion symptoms to reappear or intensify.

Postconcussion syndrome (PCS) is a collection of these cognitive, physical, and emotional symptoms that last for a varying amount of time following a concussion (Lewandowski & Rieger, 2009). Although some symptoms may be immediately evident, others may not manifest for days or weeks. Because symptoms can take time to appear and are often cognitive in nature, teachers may be the first people in the school to notice changes in their students. A child may sustain a hit or fall at recess but not show signs until it is time to concentrate or engage in a learning activity an hour later. He or she may repeat questions, answer questions slowly, or demonstrate behavioral or personality changes. Postconcussion, a child might demonstrate problems attending or concentrating; difficulty remembering or learning new information; need a longer time to complete tasks or assignments; have difficulty organizing work; demonstrate inappropriate, impulsive behavior or greater irritability; or demonstrate diminished ability to cope with stress (e.g., easily overloaded, shuts down). The student may have trouble doing more than one thing at a time, such as listening to the teacher and taking notes. The concussed individual might be bothered by bright lights and noise; the school cafeteria might be a particularly challenging location for the child. Some symptoms may resolve quickly; however, for some students, symptoms persist much longer or even worsen during the week following injury (Mittenberg, Wittner, & Miller, 1997).

Number and severity of symptoms, speed of recovery, and impact of symptoms on academic and social functioning will vary from student to student. Because concussion is not a visible injury, some school personnel may not immediately attribute a child’s difficulty to the concussion. The child may simply seem lazy or disinterested. The child himself may not attribute problems to the head injury and become frustrated or confused by his recent inability to function as he did before. Thus, a clear understanding of the signs and symptoms is critical.

Assessment

As part of the "Heads Up" materials available from the CDC, schools can obtain free checklists of symptoms for use by school nurses or other school personnel (CDC, 2010b). If a teacher or other school personnel suspects a child may have sustained a blow to the head, then the child should be sent to the school nurse, school psychologist, or another professional designated to address health issues. The evaluator observes the child for any danger signs that might require an immediate run to an emergency department, such as one pupil being larger than the other; drowsiness or loss of consciousness; a headache that gets worse and does not go away; weakness, numbness, or decreased coordination; repeated vomiting or nausea; slurred speech; convulsions or seizures; difficulty recognizing people or places; increased confusion, restlessness, or agitation; or unusual behavior. The evaluator monitors the individual for at least 30 minutes, checking for general concussion signs when the child arrives in the office, 15 minutes later, and at the end of 30 minutes (www.cdc.gov/Concussion). If the child experiences one or more signs, then the child should be referred to a healthcare professional experienced in evaluating for concussions. A copy of the checklist can be sent with the parent who picks up the child for the healthcare professional to review. The child exhibiting any signs of a concussion should never be permitted to drive home. The checklist can also be used if a student demonstrates symptoms and is suspected of sustaining a concussion outside of school.

A child who has a confirmed concussion should not be left alone for 24 hours and should be monitored for changes or deterioration over the first few hours post concussion. Children cannot always articulate symptoms or changes from normal functioning; thus, parents and teachers should be called upon to assist in concussion evaluations.

Although a complete review of assessment strategies is beyond the scope of this introductory article, school psychologists should know the basics of how students might be assessed for a concussion after the initial screening has been conducted and the child has been referred for more comprehensive medical/neuropsychological testing.

Hospital–based assessments, such as the Glascow Coma Scale (GCS), and indicators such as loss of consciousness, are only weakly related to outcome (Lewandowski & Rieger, 2009). Furthermore, many neuropsychological tests may not be sensitive enough to detect concussion–related impairments. Because few standardized tools and methods are adequate in assessing concussion in children, Gioia, Isquith, Schneider, and Vaughan (2009) propose a multilateral, multimethod assessment using standardized methods completed by key respondents (including students, parents, and teachers) that tap multiple domains of functioning. Methods of assessment include standardized tests, structured symptom–based observations, interviews, and structured symptom rating scales. The Pediatric Concussion Symptom Inventory (PCSI) is one such rating scale that involves self–reports of symptoms as well as parent and teacher reports of children’s concussion symptoms (Gioia et al., 2009). Respondents rate the extent to which symptoms were observed in the home or school setting in retrospective preinjury baseline reports and postinjury reports.

Knowledge of preinjury functioning can be an important consideration when completing a concussion assessment (McCrory et al., 2009). Your school might also implement programs in which preseason baseline neurocognitive testing is conducted to assess brain function. The athlete’s learning and memory skills, attention and concentration, and rate of thinking and problem solving is evaluated at the beginning of the season; the tests can be used again if the athlete sustains a concussion to help identify injury effects. A software program called ImPACT (www.impacttest.com) is one sports concussion management tool available to schools for this baseline testing (Lovell, Collins, & Maroon, 2002). ImPACT is a computer test that measures reaction time in milliseconds. It can be repeated as often as necessary and can be easily administered in high school computer labs. A pediatric version is available for children ages 5 to 12 years that contains age–appropriate adaptations of instructions, cognitive demands, stimuli, and format. Although ImPACT can be a useful tool, it is not a substitute for a medical evaluation or treatment, nor is it a substitute for comprehensive neuropsychological testing when needed.

When a child is being evaluated for any type of learning or behavior problem, school psychologists should include explicit questioning surrounding history of head injury (e.g., "Has your child ever hit his/her head or get hit in the head?" "Did your child ever lose consciousness or have a concussion?" "Did your child ever have surgery to the head or brain/a stroke/diagnosed with a brain tumor?"). If the parent answers "yes" to any of the above questions, the school psychologist should follow up with questions regarding problems the child may have experienced after the injury, such as headaches, dizziness, depression, anxiety, fatigue, memory problems, academic difficulties, changes in judgment, and difficulty attending or problem solving.

Prevention

We can use a tiered model to understand how concussions may be approached in a school system. Tier 1 (the bottom of the response to intervention and positive behavior support pyramids) is universal programming. In dealing with concussions, this involves establishing effective prevention programs and a school culture that promotes safety. Although accidents will happen, school psychologists can help initiate systems–level change to increase awareness in students, teachers, parents, coaches, and athletic directors regarding safety precautions that can minimize risk of concussion.

Education on potential long–term consequences of head injuries. Athletes should be taught that playing injured does not show toughness and that playing through a head injury can increase risk of repeat concussion and long–term problems, including permanent brain damage. This is one reason it is essential to have an accurate account of a brain’s history. Coaches and team staff do not always see everything that happens to players. Further, many athletes play multiple sports or sustain head injuries off the field due to other circumstances. School psychologists can emphasize the importance of clear data collection for all students, making parents, coaches, school teams, and students aware that even mild blows to the head from years ago are important to note.

Change the perception of concussions: Helmets are cool! (Concussions are not). We also need to help decrease the perception of concussions as "no big deal" or a rite of passage for athletes. To "get dinged" seems cool to some, and shedding protective devices may make some people involved with sports or recreational activities feel more "free." Personally, I admit to feeling like a dork in my helmet as my young daughters and I amble down the bike trail at one mile per hour. However, I am trying to set an example for them: Any time you get on a bike, you wear a helmet. Children can learn safe playing techniques for PE, sports, and recess. School personnel should encourage good sportsmanship at all times, encourage children to wear protective equipment that is appropriate for the activity, and check to ensure that such equipment fits properly and is well maintained.

Posters from the CDC with slogans such as "It’s better to miss one game than the whole season" can encourage young athletes to report suspected concussions and take the time necessary to recover (http://www.cdc.gov/injury/publications/index.html#tbi). A poster created by the NFL and CDC to educate young athletes on concussions was recently unveiled by the chair of the House Education and Labor Committee (Congressman George Miller, D–California). The poster is similar to the one developed for use in NFL locker rooms; it stresses the importance of recognizing concussion signs, taking time to recover, and not returning to play too soon (http://www.cdc.gov/concussion/sports/nfl_poster.html). NFL Commissioner Roger Goodell recently made a statement requesting every school to hang the poster in every locker room. He emphasized the role of the NFL in protecting young athletes from concussion, as well as the NFL’s goal to assist states with passing a return–to–play law. Rep. Miller, who is working in Congress to address concussions in student athletes, emphasized the importance of the team approach: The NFL, CDC, and Congress are working together to develop and disseminate resources and policy to positively impact student athletes’ success in the classroom and on the field. Educators need to be a key part of this collaboration. School psychologists can help distribute and discuss this information, keeping in mind the importance of broadening the message beyond school sports: All students have a chance of sustaining a concussion. Children should know how to play safely and how to recognize signs and symptoms in themselves and in classmates.

Intervention

Once a concussion is known to have occurred, our approach must deviate from the typical progression through the tiers to more intensive interventions. The school team must mobilize and immediately respond to the known concussion in a unified, informed manner with Tier 3 intensive, individualized intervention with ongoing progress monitoring. The supports and services can the gradually be reduced as the injured child recovers. Typically, a child will be instructed to rest immediately following a concussion. This includes staying home from school or limiting school hours. The child will then be permitted to return to school, with restrictions, and should not return to play or physical activities until he or she is no longer exhibiting signs of concussion. Physical activities will be permitted to resume in a graduated sequence of light exercise; running; noncontact training drills; full contact practice or training; and when completely symptom–free and, after being cleared by an approved healthcare provider, a return to play in games.

The Oregon Concussion Awareness and Management Program (2010) highlights the steps of recognize, remove, refer, and return: (a) All stakeholders must recognize the symptoms of concussion; (b) A sound policy must be in place to remove a child from school and an athlete from play immediately postconcussion; (c) The student must be referred to and seen by an appropriately trained healthcare professional; and (d) The child should then return to school and play when cleared by a medical professional, and under careful watch of all members of the school’s concussion management team.

Collaborative teams. A collaborative approach is essential in order to meet the concussed child’s needs. Team members would ideally include parents, teachers, the school psychologist, the school nurse, school counselors, and administrators (and coaches and athletic directors if the child is involved in school sports). All stakeholders should be informed about the concussion and activity restrictions. For example, if a child is in two sports, coaches for both teams must know that a concussion was sustained, even if the child is no longer demonstrating symptoms. The parent plays an especially critical role in the recovery process and development of treatment plans that include return to school, sports, recreation, and everyday home activities.

If a child demonstrates signs of a concussion, then he or she should be evaluated by a healthcare professional to determine degree of severity and to advise on return to school or physical activities. Expert consensus is that an athlete who has sustained a concussion should not return to play the same day of injury (McCrory et al., 2009). Likewise, a child with a concussion should not return to school the same day the injury occurred. The child should be cleared as symptom–free by a healthcare professional before returning to any play, such as physical education class, sports practices or games, or physical activity at recess. Children who return to play while the brain is still healing risk a greater chance of having a second concussion (www.cdc.gov/ concussion). The team should have a mindset of "we all need to work together to protect" the concussed individual. Early diagnosis and education is critical, especially to avoid reinjury. This can help minimize the risk of reinjury, especially in crowded hallways, physical education classes, and stairwells. While there is no cure for a concussion, we can help the injured individual feel better while symptomatic by providing cognitive rest and gradual reentry to school as tolerated.

The identification of one person in the school, such as the school psychologist or school nurse, to take the lead in communicating with the team of parents, school staff, and medical professionals can be most useful. This individual can coordinate meetings to communicate information about the child’s medical and educational status, clarify how postconcussion symptoms might be affecting learning and behavior, and coordinate school–based intervention efforts. If parents agree, then this might also be a good person to communicate to classmates about the student’s injury so they understand what to expect when the classmate returns to school.

Establish district policies for return–to–play guidelines. School districts need explicit policy statements, including the school’s commitment to safety and information, on when athletes can safely return to play. These statements should include guidelines requiring athletes to be kept out of play for the rest of the day of injury and until a healthcare professional who is experienced in evaluating for concussions determines the athlete is symptom–free and ready to return to play. Parents, athletes, and coaches should sign the policy at the beginning of play for each sport each season. Because successful ongoing play is important to many athletes and teams, an explicit policy can protect coaches, students, and administrators from backlash for decisions regarding removal from play. Further, it can be valuable to identify a healthcare professional who can respond to injuries during practice or competition.

The CDC has pocket cards and clipboard stickers that coaches can keep at hand with information about signs, symptoms, and emergency contacts (see http://www.cdc.gov/injury/publications/index.html#tbi). Athletes should also be trained to be aware of concussion signs and instructed to report to coaches if they suspect a teammate has sustained a concussion. Posters similar to those used by professional sports teams can be hung in locker rooms to remind athletes of signs. Coaches can follow the mantra: "When in doubt, sit them out!"

Within the past year, the National Federation of State High School Associations, the NCAA, the House Energy and Commerce subcommittee, and numerous state high school athletic associations (including the Ohio High School Athletic Association, OHSAA, in my home state of Ohio) have approved legislation setting guidelines for treating concussions or requiring schools to make explicit plans for concussion management. For example, OHSAA now requires written authorization from a healthcare professional to clear an athlete who has demonstrated concussion signs to return to play.

Modifications and accommodations at school. After returning to school, the student may need:

  • rest breaks throughout the day
  • a shortened school day
  • ore time to complete tests and assignments, or permission to complete assignments in smaller chunks
  • a quiet place to take tests and complete assignments
  • reduced assignments (particularly those that involve reading, writing, or computer work), reduced homework, or reduced course load
  • general help with school work and organization
  • removal from physical education class and physical activities during recess
  • permission to have lunch in a quiet, uncrowded space with a couple of friends
  • permission to wear sunglasses or a hat with visor to reduce sensitivity to light
  • permission to transition between classes a few minutes before or after the rest of the school to decrease chance of being jostled in the crowded hallways and stairwells

The student should limit activities that require a lot of thinking or concentration and should not participate in any high exertion activities. Both can make symptoms worse and delay healing. Social activities should be limited. A Section 504 plan may be appropriate if symptoms persist. The plan might specify appropriate environmental adaptations, curriculum modifications, or behavioral strategies.

If a child who has sustained a concussion cannot immediately return to school or recreation, then he or she might be frustrated or angry. He might feel anxious about getting behind on schoolwork or feel isolated from peers or teams. Too slow a return to school can even serve to protract a child’s recovery by causing undue stress secondary to feelings of falling behind, being away from friends, and disrupting normal family routine (Kirkwood, 2008).

Ongoing progress monitoring. Repeated evaluation of symptoms should occur by a physician with experience in treating concussions to guide recovery. The CDC has numerous resources available to increase awareness and appropriate services for individuals who have sustained concussions, including fact sheets, assessment checklists, posters, magnets, and more.

In school, teachers and staff can monitor the child for any worsening of symptoms. This should be reported to the team leader, parents, and the medical personnel responsible for monitoring the child’s progress outside of school. Worsening of symptoms typically indicates that the child has been overexerting and requires a appropriate if symptoms persist. The plan might specify appropriate environmental adaptations, curriculum modifications, or behavioral strategies.

General tests of achievement are not likely to capture the effects of concussion symptoms. Curriculum–based measures (CBM) may be more sensitive and provide a quick means of ongoing progress monitoring of academic skills. They have the added benefit of not being particularly taxing to the concussed individual who has difficulty mustering the mental stamina needed for focusing on academic material for long period of time.

Conclusion

Clearly we do not know everything about concussions. Although individuals often seem fine after recovering from a concussion, we do not yet know about the long–term damage being done. Little research exists regarding concussions, particularly in children. Concussion education and response is a key part of having safe, healthy schools. With a coordinated effort and continued dissemination of information, we can work together to prevent, recognize, and respond appropriately to concussion.

References

Buzzini, S. R., & Guskiewicz, K. M. (2006). Sport–related concussion in the young athlete. Current Opinion in Pediatrics, 18, 376–382.

Centers for Disease Control and Prevention. (2010a). Injury prevention & control: Traumatic brain injury. Retrieved from http://www.cdc.gov/traumaticbraininjury

Centers for Disease Control and Prevention. (2010b). Heads up: Concussion in youth sports. Retrieved from http://www.cdc.gov/concussion/HeadsUp/youth.html

Centers for Disease Control and Prevention. (2007). Nonfatal traumatic brain injuries from sports and recreation activities—United States, 2001–2005. Morbidity and Mortality Weekly Reports 2007, 56(299), 733–737.

Collins, M. W., Lovell, M. R., Iverson, G. L., Cantu, R. C., Maroon, J. C., & Field, M. (2002). Cumulative effects of concussion in high school athletes. Neurosurgery, 51, 1175–1179.

Collins, M. W., Iverson, G., Lovell, M. R., McKeag, D. B., Norwig, J., & Maroon, J. (2003). On–field predictors of neuropsychological and symptom deficit following sports–related concussion. Clinical Journal of Sport Medicine, 13(4), 222–229.

Gioia, G. A., Isquith, P. K., Schneider, J., & Vaughan, C. G. (2009). New approaches to assessment and monitoring of concussion in children. Topics in Language Disorders, 29, 266–281.

Guskiewicz, K. M., McCrea, M., Marshall, S. W., Cantu, R. C., Randolph, C., Barr, W., et al. (2003). Cumulative effects associated with recurrent concussion in college football players: The NCAA Concussion Study. Journal of the American Medical Association, 290, 2549–2555.

Hoge, C. W., Goldberg, H. M., & Castro, C. A. (2009). Care of war veterans with mild traumatic brain injury–flawed perspectives. New England Journal of Medicine, 360(16), 1588–1591.

Kirkwood, M. W., Yeates, K. O., Taylor, H. G., Randolph, C. R., McCrea, M., & Anderson, V. A. (2008). Management of pediatric mild traumatic brain injury: A neuropsychological review from injury through recovery. The Clinical Neuropsychologist, 22, 769–800.

Langlois, J. A., Rutland–Brown, W., & Wald, M. M. (2006). The epidemiology and impact of traumatic brain injury. Journal of Head Trauma Rehabilitation, 21, 375–378.

Langlois, J. A., Rutland–Brown, W., & Thomas, K. E. (2006). Traumatic brain injury in the United States: Emergency department visits, hospitalizations, and deaths. Atlanta, GA: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control.

Lewandowski, L. J., & Rieger, B. (2009). The role of a school psychologist in concussion. Journal of Applied School Psychology, 25, 95–110.

Lovell, M. R., Collins, M. W., & Maroon, J. (2002). ImPACT: The best approach to concussion management, user’s manual (Version 2.1) [computer software and manual]. Pittsburgh, PA: ImPACT.

McCrory, P., Meeuwisse, W., Johnson, K., Dvorak, J., Aubry, M., Molloy, M., et al. (2009). Consensus statement on concussion in sport: The 3rd International Conference on Concussion in Sport, held in Zurich, November 2008. Journal of Clinical Neuroscience, 16, 755–763.

McGrath, N. (2010) Supporting the studentathlete’s return to the classroom after a sport–related concussion. Journal of Athletic Training, 45, 492–498.

Mittenberg, W., Wittner, M. S., & Miller, L. J. (1997). Postconcussion syndrome occurs in children. Neuropsychology, 11, 447–452.

Oregon Concussion Awareness and Management Program. (2010). Max’s law: Concussion management implementation guide for school administrators. Eugene, OR: Western Oregon University Center on Brain Injury Research and Training.

Yeates, K. O., & Taylor, H. G. (2005). Neurobehavioral outcomes of mild head injury in pediatric populations. Seminar in Pediatric Neurology, 8, 5–16.


Susan C. Davies, EdD, is an assistant professor in the school psychology program at the University of Dayton.