Return to Learn Concussion Guidelines Every Parent Should Know

When a child has a concussion, the rules for getting back to sports are laid out by state Return to Play laws. But when it comes to getting back to the classroom, the rules aren’t as clear.

A recent study in the journal Pediatrics found that only a few states have Return to Learn concussion laws, and these varied in terms of responsibility. Some of the laws were restricted to student athletes, excluding students who sustained non-sport related concussions.

“When returning a student to the classroom after a concussion, we try to balance stimulation levels and worsening of symptoms,” explains Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s. “While too much cognitive exertion can lead to headaches, problems concentrating, fatigue and trouble with emotional control, over restriction from classroom and academic activities can result in social isolation and anxiety about falling behind or lower grades that can also slow the recovery process.

return to learn
Dr. Chris Koutures, a board certified pediatrician and sports medicine specialist at CHOC Children’s.

“Returning to the classroom after a concussion optimally takes a team approach including the student, family, medical and education teams,” Dr. Koutures says. “Flexibility and creativity in paying attention to individual student needs and concerns can make this process more rewarding for all parties.”

Dr. Koutures advises the patient’s care team, including parents, to follow CHOC’s recommended six stages for returning a student to school after a concussion, including the following added guidelines:

Step-wise Return to Learn Progression

Step 1: No formal academic activity

  • Recent studies suggest that full or prolonged limitations in cognitive activity may actually delay recovery
  • In first few days after concussion, allow 15-20 minute intervals of single-task activities that do not provoke symptoms and are not excessively taxing
    • Listen to light music
    • Draw or color
    • Journal writing
    • Audiobooks
    • Passive television or movies (at home), larger screen preferred, lower volume
    • Some texting, smartphone use; want to balance maintaining key social contacts with not having symptom-flare
    • Conversations with 1-2 other people
  • Separate the 15-20 minute bursts of activity by 30-40 minutes minimum of non-cognitive activity
  • If symptoms flare before 15-20 minute limit, stop activity and try again later
  • If patient can handle 2-3 periods of 15-20 minute activity over the course of day, can consider advancing toward partial return to school

Step 2: Light academic activity

  • Attend 1-2 periods or 1-2 hours of school
  • Select consecutive classes; have child help make decision
  • No physical education or other activity classes
    • Caution with more noisy classes such as woodshop, music/band, chorus
  • Tend to avoid first class in morning to allow more sleep and arrival at school without busy parking lot and hallways
  • Main goal: be in class; no responsibility for note-taking, participating in class /responding to teacher, in-class work, homework or testing
    • Audible learning (most kids handle this better than visual learning after a concussion)
    • Should have pre-printed notes for reference or have others take notes and share
  • Sit away from louder students, windows, projectors, or other light/noise stimulation
  • Sit close to teacher
  • Allow to wear earplugs and sunglasses as needed
  • May allow brief 1-2 minute periods of putting head on desk for rest
  • May leave class early to avoid the noise and commotion of hallways during passing periods

Step 3: Increased academic activity

  • Expand day to 3-4 periods or hours per day
  • Incorporate break periods (nutrition break, lunch)
    • Have quiet place to rest
  • Recommend against assemblies or rallies due to noise stimulation
  • Continue to avoid physical education or activity classes
  • Main goal is to be in class and handle longer day; still not responsible for note-taking, participating in class/responding to teacher, in-class work or homework

Step 4: Full-time attendance

  • Full-day attendance without activity or other higher-stimulation classes
  • May expect some increased fatigue at end of school day
    • If student wants to nap after school, limit to no more than one hour
  • May start to take own notes, though helpful to have pre-printed teacher’s notes or other student notes
  • Incorporate “to do” lists with short-block (10-15 minute) work periods followed by short (5 minute) breaks
  • Break period and breaks in class (especially if block schedule) may still be needed
  • If possible, move most challenging courses to time of day when student feels the best

Step 5: Return to Majority of Academic Activities

  • Once handling full day attendance, can resume taking notes in class, verbal responses to teacher, and in-class work
  • May begin homework starting with limits to 30-60 minutes a night and priority on essential concepts that are needed for eventual testing or continuity of learning
    • Waive any projects, papers, essays or other assignments that are not required for future learning needs
    • Try to limit burden of make-up work; focus should be on those assignments that are necessary for future learning
      • Sequential classes (math, foreign languages, science) tend to be the most challenging for make-up work
    • No tests or quizzes at this stage
    • Audible learning – listen/speak responses vs. writing, dictating work, audiobooks may be more favorable at this point

Step 6: Return to Full Academic Activity

  • Full-day attendance without symptoms, fulfilling all in-class duties and completing usual homework assignments
  • Can resume tests and quizzes
    • Strongly consider waiving missed tests or quizzes
    • Combine missed tests or quizzes to allow more quick completion of make-up work
    • Allow student to take missed tests/quizzes to gain exposure/mastery of material without being graded, or only receive grade if results are in usual level of achievement
    • Assign grades at end of grading period based on level of work prior to concussion
  • May need more time for test completion
  • May need individual room placement for testing
  • May limit testing/make-up testing to one test per day
  • May allow open book, use of notes, word banks or home-based testing
  • Consider alternate forms of testing such as spoken test, or multiple choice vs. longer essay responses that might be more taxing for the student
  • Students may still benefit from more audio learning
  • Can resume physical education (with physician release) and activity courses
Learn about the CHOC Children’s Concussion Program now.

<em>Related posts:</em>

  • Concussion Program Prescribes At-Home Exercises
    Athletes and other adolescents with mild to severe concussions who experience symptoms such as dizziness, feeling unbalanced on their feet, blurred vision or trouble focusing on objects, may be good ...
  • The Power of Holistic Care
    Zac McNeese laced up his first pair of hockey skates before his third birthday. By the time he turned 7, his competitive team was traveling all over the country and ...
  • Preventing and Treating Concussions
    CHOC Children’s multidisciplinary team of concussion experts can help prevent and treat concussions, as well as help patients ease back in to school and sports. Careful supervision is essential for ...

Concussion Program Prescribes At-Home Exercises

Athletes and other adolescents with mild to severe concussions who experience symptoms such as dizziness, feeling unbalanced on their feet, blurred vision or trouble focusing on objects, may be good candidates for at-home visual and vestibular exercises recently designed by experts of the CHOC Children’s concussion program.

“Concussions are like puzzles, and every one is a little bit different,” says Dr. Jonathan Minor, a CHOC sports medicine specialist. “As many as fifty percent of concussed athletes may experience these symptoms and could benefit from these exercises that may get them back on the field or back in the classroom sooner.”

concussion exercises
Dr. Jonathan Minor models one of several at-home exercises recently designed by experts of the CHOC Children’s concussion program.

The convenient and self-explanatory exercises are ones that athletes and students can perform at home, but should only be started under the guidance of a concussion specialist, after an appropriate evaluation, and as part of an overall post-concussion treatment plan. These exercises are intended to enhance and improve a patient’s recovery from a concussion.

“Patients should be aware that beginning these exercises may stimulate some symptoms for a short period of time, such as trouble focusing, dizziness, nausea or headaches. But after just a few days of daily exercises, they may find that they can tolerate each exercise for a longer period of time,” says Minor, who is a lifetime athlete himself.

“We encourage our patients to only perform these exercises for the duration tolerated, rather than endure and push through worsening symptoms initially. Seeing a difference quickly with improved tolerance resonates especially with athletes, who are used to training and then seeing improved results.”

Download your copy of the vestibular/balance exercises and the visual concussion home exercises.

Related articles:

The Power of Holistic Care

Zac McNeese laced up his first pair of hockey skates before his third birthday. By the time he turned 7, his competitive team was traveling all over the country and being coached by former professional players. A series of concussions prematurely ended his time as a nationally ranked hockey player at the age of 14 and kept him out of school for months. Thanks to holistic care treatments through CHOC Children’s integrative health services, working in partnership with CHOC’s concussion program, Zac is back in school and getting the chance to be a normal teenager again.

Zac McNeese
Zac began playing hockey at age 3.

Three Concussions in Two Years

Zac’s first concussion occurred during a hockey tournament in Canada. A hit to the head with a hockey stick rendered him unconscious for a short time, followed by short-term memory loss. He was taken to the nearest emergency room for evaluation. After a six-week stint out of school and sitting out of hockey for another few months, he returned to the sport he loved.

But three games into his return he suffered a whiplash-style concussion. Although this one was milder than the first, its proximity to the last injury concerned Zac’s doctors. His family was familiar with the medical benefits of acupuncture, so his parents convinced him to give it a try in hopes of relieving chronic headaches and back pain that was lingering from his second concussion.

“It took some time for me to warm up to the idea of acupuncture, but my older brother had these treatments done when he was a patient at CHOC, and I knew how much they had helped him, so I finally decided to try it for myself,” says Zac. “Over time I saw results and could feel it helping my neck and back problems.”

He began acupuncture treatments with Ruth McCarty, director of Chinese medicine and acupuncture at CHOC.

“The goal of acupuncture treatments is to improve the quality of life for our pediatric patients with diverse medical problems by providing benefits that complement their other medical treatments. Acupuncture isn’t invasive or scary, and it helps you relax.” explains Ruth. “If you can’t relax, it’s impossible to start healing your other ailments.”

The National Institutes of Health have critically evaluated clinical studies and concluded that acupuncture is effective for a variety of medical problems including management of pain and headaches, added Ruth.

Other treatment methods Zac benefitted from include massage, aromatherapy, herbal supplements, yoga and meditation helped improve Zac’s headaches and depression, says Zac’s mom Dana.

A year later Zac suffered another, more serious concussion. During a hockey game, he got hit from behind and was knocked unconscious while mid-air, then fell and hit his head. He was paralyzed from the waist down for 36 hours and doctors ran numerous tests to scan for permanent damage. After a few days of observation, he was sent home to rest in a neck brace, but wouldn’t return to school for several more weeks.

Zac McNeese
Zac was hospitalized after his third concussion.

A New Normal

Zac’s care team said he could not play hockey again, for risk of future injury. The news was devastating to the young man who had given up countless social activities over the years to dedicate himself to hockey.

“When my doctors said I couldn’t play hockey ever again, at first it just felt like a break, like my season had ended and I would be back on the ice soon with my teammates,” says Zac. “But after six months of not playing, it finally hit me that I was never going back to the sport I loved and had played for almost my entire life.”

Zac struggled with chronic anxiety and bouts of depression while he dealt with this news. He also struggled with acclimating to high school. He’d been a straight-A student for years, but he now had trouble concentrating. He also experienced hyperreflexia, meaning his reflexes were overactive and his legs often twitched and bounced.

He decided to try home-schooling as he continued working on his recovery, which included more frequent sessions with Ruth and ongoing monitoring by neurologists in CHOC’s concussion program.

That break from school turned out to be as beneficial for his health as it was for his mind.

“Now I want to help other kids going through this. When I got my concussions, I didn’t know anyone else who had gone through it,” Zac says. “But I want to encourage other kids to be open minded about talking to someone about how you’re feeling, and don’t be stubborn about alternative treatments.”

Zac McNeese
Zac was recently able to return to school thanks to the help of his holistic treatments at CHOC in partnership with the CHOC concussion program.

To fill the void, Zac has taken up lower-impact sports like tennis and golf. He now has time to explore his new interests, like playing guitar and piano. He remains under the care of a CHOC neurologist and continues weekly treatments with Ruth.

“He’s a very resilient kid, but he wouldn’t be where he is today and be back in school without being open to alternative medicine and being able to talk to someone about his sense of loss, and how he was going to move forward,” says Dana.

Related articles:

Preventing and Treating Concussions

CHOC Children’s multidisciplinary team of concussion experts can help prevent and treat concussions, as well as help patients ease back in to school and sports. Careful supervision is essential for young persons with concussions, since their brains are still developing.

In this episode of CHOC Radio, Dr. Sharief Taraman, a pediatric neurologist, Dr. Jonathan Minor, a sports medicine specialist, Jenn Ahlswede, a speech language pathologist, and Mollee Oh, a physical therapist and rehabilitation supervisor, discuss:

  • SCAT3, an assessment tool parents and coaches can use immediately after an incident occurs
  • The film “Concussion,” and how concussions affect kids and teens differently than adults
  • Recommendations for cognizant and physical rest periods after sustaining a concussion

Hear more from CHOC experts in this podcast.

CHOC Radio theme music by Pat Jacobs.