Abstract
PURPOSE:
The purpose of this article is to familiarize healthcare providers and parents with educational language, laws, and processes as they relate to a comprehensive ascending level of academic supports as it pertains to promoting a smooth and supported transition to school following a concussion.
BACKGROUND:
Returning to learn (RTL) following a concussion is of parallel importance to returning to sport (RTS). A successful RTL is a critical part of concussion management. Many RTL articles advise healthcare providers and parents to request formalized educational supports, also known as Tier 2 or Tier 3 services, for children with concussion as they return to school.
FINDINGS:
Premature requests for formal (Tier 2 or 3) educational services, rather than allowing for immediate informal educational supports (known as Tier 1), can actually delay academic supports and have the potential to cause adversarial relationships between parents and schools. Additionally, this practice contradicts current research demonstrating the need for fast, flexible, temporary academic supports within the first month post-injury.
CONCLUSION:
Allowing school districts to direct the application of existing ascending levels of educational support for students with concussion as they return to school can promote robust and positive outcomes.
Keywords
Introduction
According to the Centers for Disease Control (2017), the incidence of sports-related concussions is 2.5 million annually in the United States. Without a systemic approach to capture the actual number of concussions occurring in non-sports related activities, as well as for those never evaluated by a health care provider, the true number of youth concussions is unknown. Return to Play/Sport (RTP/S) legislation in all 50 states and the District of Columbia has driven the field of concussion forward with respect to safer return to sports. However, until recently, there has been scant attention paid to return to learn (RTL). In 2013, the American Academy of Pediatrics Clinical Report on returning to learning following a concussion states that a student should return to school when symptoms are “tolerable, short-lived, and/or amenable to rest and intervention” (Halstead et al., 2013, p. 952). The 5th Consensus Statement on Sports Concussion reinforces the concept of a successful return to school before return to sport (McCrory et al., 2016). A number of states are attempting to draw attention to RTL by contemplating RTL legislation. However, the down side of aligning RTL legislation with RTP legislation is that it would focus academic supports only on students with sports-related concussions. Parents, educators and health care providers are beginning to recognize that while not all students with a concussion will return to sports, all students with a concussion will need to transition back to school.
Definition
Concussion, which is an external blow or jolt to the head resulting in physical, cognitive, emotional and energy symptoms, typically has short-term effects. In a large-scale study of 5 to 18 year olds followed after an emergency visit for concussion, 70% had symptom resolution within 28 days (Zemek et al., 2016). Another emergency room study assigned a control group to 1 to 2 days of rest followed by gradual re-introduction of activity. The intervention group was assigned to 5 days of strict rest. The intervention group demonstrated higher reports of symptoms and slower recovery than the control group suggesting that more rest is not necessarily beneficial for concussion recovery (Thomas et al., 2015). Further evidence shows that a concussion can have relatively short-term effects on learning, possible academic dysfunction for up to 1 month (Wasserman et al. 2016) with minimal impact on long-term academic performance (Russell et al., 2016). Extrapolating from the data above, given that 70% of students who transition back to school following a concussion may only need academic supports for up to one month, but given those students will need those academic supports immediately upon school re-entry, it is clear that there can be no delay in the RTL plan.
There are three educational levels of ascending support that schools regularly employ for all students (athletes and non-athletes) with emerging learning, behavioral, and social concerns. The goal of these ascending levels of support is to provide early screening, quick intervention, and progress-monitoring. This array of supports should be applied to students returning to school following a concussion. The first level of support, called the Universal Level (Tier 1), is the general level of entry that all students with a concussion should enter in to upon return to school. This initial first stage of informal academic supports gets little attention. Increasing numbers of RTL articles have been published, written by professionals outside of the educational system that regularly recommend students who experience a concussion should return to school at a higher level (Tier) of academic support, such as at Tier 2 (e.g., Section 504 Plan) or Tier 3 (e.g., special education through an Individual Education Program (IEP)). Without understanding the nuances of the educational system, these professionals inadvertently promulgate misinformation that may potentially delay academic supports for students with concussion and risk contributing to protracted recovery. This paper will define existing educational supports and law focusing first on widespread interventions suitable for the 70% of students who recover in the typical one month timeframe, followed by options for the 30% of students who need higher levels of support due to protracted recovery.
Ascending levels of educational support
All schools have an obligation to support students who struggle academically regardless of the underlying cause of their difficulties. Historically, all children in the United States, regardless of their disability, have the right to a Free Appropriate Public Education (FAPE). This right is guaranteed under the Rehabilitation Act of 1973 and the Individuals with Disabilities Education Act (IDEA). Navigating the school-based processes that entail requesting an evaluation and understanding the various types of services available for students can be confusing for those unfamiliar with the field of education. Over the years, schools, states, and the federal government have developed philosophical, legal, and ethical processes to informally and formally support students with varying levels of need to ensure that students with disabilities are neither under or over-represented (IDEA, 2006; Section 504, 1973). The following is a description of the various educational support levels and a cursory explanation of educational law.
Framework of ascending support levels
It is best practice that schools support all students who experience issues with learning. The first line of defense begins with early screening, assessment, and intervention in the least restrictive environment, the general education classroom. If additional needs are identified, a systematic and logical process allows for transition to more intensive academic supports based upon collected data and educational need. Educational law dictates that all public schools must offer ascending levels of academic support to students demonstrating educational need. School districts refer to those educational supports by various names (e.g. Tiers, levels) and common examples include initiatives such as the Multi-Tiered System of Support (MTSS) or Response to Intervention (RTI) (U.S. DOE, 2006). There are three ascending levels of support for students who have educational impact related to any number of medical, psychological, behavioral or social causes. A description of the focus of each level is explained below and applied to concussion.
Focus of ascending levels of academic support and their application to concussion
Universal level, Tier 1
At the universal level of intervention, students receive informal assistance within the general education setting. Any student experiencing difficulty with learning or behavior can be quickly screened and monitored. General education supports are applied promptly, liberally, and frequently as determined by the general education teacher. These academic adjustments are unencumbered by meetings or paperwork delays. Academic adjustments are driven by teacher collected classroom observations and data and supports can fluctuate as the teacher deems necessary. An Individualized Health Plan (IHP) is often created for a student with a medical condition. An IHP is a tailor-made plan for students whose healthcare needs affect or have the potential to affect the student’s safe and optimal school attendance and academic performance. This plan is developed in collaboration with the student, family, and healthcare providers. Where available, school nurses often facilitate the development of IHP’s, unencumbered by meetings, significant paperwork, or time delays. An IHP is sometimes initiated at Tier 1 but can also be initiated at Tier 2.
Universal level applied to concussion
Because the majority of students with a concussion transition back to school within days of the injury, the highest yield of support for a student in the acute phase (initial 1 to 4 weeks) of a concussion takes place within the general education classroom. In order for RTL to be immediate and effective, general education teachers must be be trained and empowered to front-load academic supports within the first 4 weeks and should fade academic supports as the concussion symptoms subside. An IHP in many instances may be an ideal safeguard for use in the RTL process for students following a concussion (National Association of School Nurses, 2016; Zirkel & Eagan Brown, 2014). Since 70% of students with a concussion resolve within one month, having an IHP can be one of the most efficient ways to provide support during the acute phase of recovery.
Targeted level, Tier 2
If support at the universal is not adequate, an intermediary level of more customized support is implemented at the Targeted Level or Tier 2 level. Students who do not improve at the universal level may need more targeted, formal interventions. Tier 2 interventions are applied in a more tailored and focused manner. There are two formalized plans utilized at the Tier 2 level. As stated above, an IHP is a common option schools employ at the Tier 1 or 2 level. The most commonly employed Tier 2 support is a Section 504 Plan. Section 504 of the Rehabilitation Act is a federal civil rights law that provides protection if a person has: (1) a physical or mental impairment (2) that limits one or more major life activities (3) to a substantial extent. (Section 504 of the Rehabilitation Act of 1973). A 504 Plan may be considered if a medical condition substantially limits at least one of the major life activities (e.g., thinking, concentrating, reading, sleeping, or learning).
Targeted level applied to concussion
A 504 Plan may prove to be an ideal mechanism for use in the RTL process for symptoms that are severe and/or long-lasting resulting in educational need (e.g., beyond 1 month) (McAvoy & Eagan Brown, 2015). There is no established timeframe for when a school district should initiate a 504 Plan for a student with a concussion. Instead, the determination must be based upon whether a major life function has been substantially impacted by the student’s concussion. The determination for qualification under a 504 Plan should consider duration and need: Duration of the concussion symptoms and the need for formalized academic accommodations. A 504 Plan can occur within any Tier level. However, implementing a 504 Plan during the first several weeks post-concussion would be precipitous unless there is a substantial need.
Intensive level, Tier 3
If a student’s educational need cannot be supported through Tier 1 or 2 level interventions, an Intensive Tier 3 level of support is required. At the Tier 3 level, a student must demonstrate that s/he is unable to benefit from general education supports alone and/or requires specialized instruction, placement, programming, and modification to the curriculum. This level is the most intensive level a school can provide, and is commonly referred to as special education. At this level, academic modifications are required. Prior to entering this level of intensive academic support, there is typically a trail of data collection that occurred during the student supports provided at Tiers 1 and 2. Additionally, this level requires official parent notification and permission to evaluate the student. Permission and evaluation can span several months, and may result in a team (parent, health care provider, and school) decision for special education eligibility under the Individuals with Disabilities Education Act (IDEA) resulting in the creation of an Individualized Education Program (IEP).
Intensive level applied to concussion
The Tier 3 level is the most intensive, and protected level of all educational supports and services. Interventions at Tier 3 come with significant federal regulatory oversight that hold schools accountable for student educational progress and monitoring. The process to qualify for special education services can commonly take up to months (not including summer months) to complete. However, the great majority of concussions are short-term, transient injuries that rarely rise to the level of causing a disability resulting in permanent brain damage. Therefore, it is uncommon that a concussion would result in an IEP for special education services and supports. Although, there are rare instances when a student with a concussion (and a history of prior concussions) fails to recover and requires an evaluation for more formal intensive special education services, supports, and placement options outside of the general education setting. If an IEP is warranted following a concussion, the primary exceptionality category would be Traumatic Brain Injury (TBI) (IDEA, 2006).
Contrary to popular belief, there is no legislation requiring medical clearance for the addition or deletion of academic supports (adjustments, accommodations, or modifications) following a concussion. The concussion-trained general education teacher should be empowered to make all initial decisions regarding what universal academic adjustments a student with a concussion requires during the first several weeks. Medical input from a health care provider should be considered if it is available. However, a school team should not, and often cannot, wait for medical guidance to determine appropriate academic adjustments.
Ascending levels of academic support applied to concussion
Ascending levels of academic support applied to concussion
See Table 1 for a summary of the ascending levels of academic support as they apply to concussion.
Concussion research now demonstrates that total rest does not promote faster concussion recovery. However, many authors, without the nuanced expertise of educational initiatives and safeguards, promote RTL recommendations in the literature suggesting that more intensive educational supports are better educational supports. Conversely, this is not the case. Additionally, a 504 Plan or IEP services and supports cannot simply be executed following a parent or physician request. There is a well-regulated and transparent process that must take place. A written or oral request from a parent for a special education evaluation sets into motion a chain of events that must be documented by the school. When a request for a special education evaluation is received, the school district has a legal obligation to consider the request. IDEA sets a timeframe of 60 days, however, each state may choose to set it’s own timeframe. For example, in Pennsylvania, after written parent consent, the district has 60 business days (excluding summers) to complete the initial evaluation and present it to the parent (Pennsylvania Department of Education, 2014, April). Documenting due diligence is time consuming and labor intensive for schools. The process involves school-based team meetings, classroom observations, informal and formal testing, and report writing. If a 504 Plan or IEP is requested prematurely, the concussion will typically resolve before the school staff has a chance to complete or submit their evaluation reports. Requesting a 504 Plan or an IEP too quickly following a concussion is educationally unsound, undermines the existing school system processes, and more importantly, can delay academic supports for students with concussion by diverting time and energy into legal or policy-based processes.
Preparing school staff
Providing concussion training focused on return to learn management for all school staff is the first step to empowering educators. Concussion training will provide educators with the knowledge and understanding regarding how concussion return to learn management fits within a school’s existing ascending tiered levels of support. These tiered levels of support serve as a screening mechanism to determine which students respond well to the universal application of academic adjustments and which students rise to a level requiring more customized academic accommodations or intensive academic modifications. By profession, educators are the experts in supporting students with learning needs. What educators may not yet have is the knowledge and management skills required to understand how concussions and return to learn fit into their current educational practices.
Conclusion
In summary, there is new and compelling data addressing the return of a student to school following a concussion. The evidence suggests that concussions have a favorable outcome; 70% of students with a concussion will resolve within 28 days. The evidence also shows that most students with a concussion may miss a few days of school initially, but should then promptly return and resume some level of cognitive activity. Upon a student’s return to the classroom, school staff should be prepared to immediately support students at the Tier 1 level. Concussion training for all general education teachers will enhance their ability to support concussion symptoms effectively. It is of concern that RTL recommendations made by non-educators, may promulgate Tier 2 or Tier 3 points of entry immediately upon a student’s return to school. In a large high school, where school staff may manage over 100 concussions per year, incorrect RTL information to parents or medical provider suggesting they request 504 Plans or IEPs, can set into motion an unnecessary burden and strain on school staff time, energy, and resources. The RTL discussion continues to emerge as a critical part of school-based concussion management. Since educators know schools, educators should be leading concussion return to learn guidance for their parents and local health care providers. A consistent school-based implementation of ascending Tiered Levels of academic supports for students who experience concussion is not only helpful to student recovery, but is reassuring to parents and health care providers.
Conflict of interest
None to report.