Concussions Hurt Academic Learning And Performance of Children and Teens

Student-athletes who experience lingering concussion symptoms and their parents worry more about the negative effect of concussion on learning and school performance, report more school-related problems, and more classes posing difficulty than students who recover more quickly, finds a 2015 study in the journal Pediatrics. (1)

The study found that high school students who have not yet fully recovered from concussion (e.g. had not returned to baseline on neurocognitive tests and were still experiencing concussion symptoms) are particularly vulnerable to school-related problems as compared to elementary and middle school students.  

Not surprisingly, the study also reports that the severity of post-concussion symptoms is directly related to the extent of school-related problems experienced by students, no matter the grade.

Despite growing recognition that a concussion can negatively affect children and adolescents in various aspects of their lives, including home, school, social relationships, and sports, and a developing consensus on the need for evidence-based guidelines to govern a gradual return-to-school process for students recovering from concussion (a consensus which prompted the American Academy of Pediatrics in a 2013 clinical report (2) to recommend a framework for multidisciplinary care to support students’ return to learning), the study is the first to examine the nature and extent of the academic effects of concussions among student-athletes.

The study notes that “poorly specified or inconsistent recommendations across providers and a lack of standard communication channels between medical teams and school personnel” often contribute to student-athletes experiencing academic problems after concussion, but that the association between symptoms and adverse academic effects identified in the study “highlights the key role of the medical-school partnership in guiding a successful return to school.” 

Identifies three needs

Lead author Danielle Ransom, a postdoctoral fellow at Children’s National Health System in Washington, D.C., and her colleagues said the findings identified three practical needs:

1. A need to reassure students and families that the school will support return to learning.  “The high level of concern about postinjury school performance implies the need to deliver early reassurance to students and families that their academic needs will be met,” writes Ransom.
2. A need to provide targeted support, particularly at the high school level.   “[T]he range of reported postinjury problems … [such as] increased time spent on homework, headaches interfering with learning, suggests a need to provide actively symptomatic students with targeted supports during the postinjury period,” Ransom said, “particularly for older students, who face greater academic demands [than their] younger peers.”
3. A need to develop and implement a symptom-relevant set of academic accommodations. To minimize the risk that adverse postinjury academic effects of concussion, such as failure to complete homework, problems keeping pace with an increased workload, and the perception by students and parents that symptoms are being poorly controlled, will lead to potentially negative outcomes, including the onset of depression and anxiety and a prolonged recovery, the authors recommend the development of a symptom-relevant set of academic accommodations for students recovering from concussion, with school personnel implementing, monitoring, and adjusting supports throughout the recovery period.  The study recognizes that there is currently no expert consensus on a protocol for return to school during concussion recovery. “It is imperative that any standardized protocol of post-injury academic recommendations is predicated on an empirically-based understanding of the academic effects of concussion, not just speculation,” writes Ransom. “By examining the frequency and types of academic issues faced by students during concussion recovery, and what students are most affected, evidence-based guidelines can be developed for guiding the return to school.”

Important study

“This work provides very important evidence – the first of its kind – to document the level of concern about academic functioning that students and their parents have while they are still in recovery from a concussion,” said sports concussion neuropsychologist Neal McGrath of the Sports Concussion New England, who was not involved in the study. McGrath viewed the study as “strong work from neuropsychologists who have led the way in our understanding of return-to-learn issues.”

Importantly, noted McGrath, the study’s findings ” are very consistent with the clinical observations reported by many concussion management specialists over the past several years, namely, that symptomatic students often experience very substantial problems in school, that they often find more difficulty in classes involving math and greater reading demands, and that these issues are more prominent at the high school level where academic pressure is greater.” McGrath shared the author’s recommendation that, “What students in concussion recovery need at school is individualized support for their symptoms and learning problems.” (Such an individualized approach is also recommended by the AAP in its 2013 clinical report)(2)

McGrath’s comments were echoed by sports concussion neuropsychologist Rosemarie Scolaro Moser, author of Ahead of the Game: A Parents’ Guide to Youth Sports Concussion and Director of the Sports Concussion Center of New Jersey. It “reinforces what we as clinicians have all along suspected in our practices, and now provides data for advocacy efforts in schools,” said Moser.

Study details

Researchers at Children’s National Health System, George Washington University School of Medicine, and the Brady School of Medicine at East Carolina University, studied a group of 349 youths aged 5 to 18 years who were evaluated in an outpatient concussion clinic at a large regional medical center within 28 days of injury, dividing them and their parents into two groups, depending on their recovery status at the time of the visit: (1) actively symptomatic/not yet recovered (as defined by elevated symptoms and/or impaired performance on neurocognitive tests, and (2) recovered (as defined by no elevation of symptoms and no impairment of neurocognitive test performance). The two groups were then further divided based on level of schooling.

Researchers expected to find that symptomatic students and their parents would report greater postinjury academic difficulties along a number of lines, with more widespread effects reported by students in higher grade levels, and that greater symptom severity would be associated with more adverse academic effects.

Comparing student and parent responses to the question, “How concerned are you about this injury affecting (your/your child’s) school learning and performance?”, the researchers found significant differences in reported level of concern based on recovery status and level of schooling with much higher percentages of students who had not recovered from their concussions and their parents (roughly six in ten) reported feeling moderately or very concerned versus roughly one in six students (16%) and one in three parents (30%) in the recovered group.

While parents of students who were still experiencing concussion symptoms reported generally consistent levels of concern across the three levels of schooling, the level of concern reported by students varied, with two-thirds (67%) of high school students saying that they felt moderately or very concerned versus only about half (52%) of middle school and four in ten (38%) elementary school students.

Not surprisingly, students still experiencing concussion symptoms reported significantly more postinjury school problems than their recovered peers. Nearly nine in ten (88%) reported one or more school problems related to concussion symptoms such as headache, fatigue, and problems concentrating; nearly eight in ten (77%) likewise reported diminished academic skills (e.g. difficulty taking notes, spending more time on homework, problems studying) versus a minority of students who were no longer experiencing symptoms (38% and 44%) respectively.

Students who continued to experience symptoms and their parents were also significantly more likely to report trouble in one or more classes than students who had recovered and their parents, although nearly half of the latter group of students and one third of their parents reported trouble in one or more classes during concussion recovery. High school and middle school students and parents reported trouble in significantly more classes than elementary school studnets and parents, with math being the most problematic subject across grade levels, followed by reading/language, arts, science, and social studies.

Students and parents in the unrecovered group perceived the effect of concussion on grades differently than those in the recovered group, with a large majority of students and parents in the former group believing grades in one or more academic subjects had been affected after concussion, while fewer than half of the students or parents in the recovered group reported a change in grades.

Sources:

1. Ransom DM, Vaughan CG, Pratson L, Sady MD, McGill CA, Gioia GA. Academic Effects of Concussion in Children and Adolescents. Pediatrics 2015;135(6). doi:10.1542/peds.2014-3434)(published online ahead of print May 11, 2015)
2. Halstead ME, et al. Council on Sports Medicine and Fitness; Council on School Health: Returning to learning following a concussion. Pediatrics. 2013;132(5):949-957

Recommended for further reading/watching

Return to Learn Just As Important As Return to Sports, AAP Says 
Return to Learn After Concussion: Modify School Environment To Avoid Triggering Symptoms (video)
Return to Class After Concussion Different for Every Student (video)
Academic Accommodations After Concussion (video)
More Post-Concussion Help For Students In Classroom Needed
Post-Concussion Strategies for the Classroom
Recovering from Concussion: Teachers Play Important Role