CHAPTER 3
The Concussion Team Model
When any health issue affects a student, school personnel are expected to communicate effectively with one another, with the family, and with medical personnel. Whereas a number of medical situations, such as a student’s chronic illness, might develop over time, a concussion occurs in an instant and requires a knowledgeable group of individuals in the school building—with a designated leader—who can quickly and efficiently mobilize to meet the student’s needs. A multidisciplinary team approach is best practice in concussion management (Halstead et al., 2013; McAvoy, 2011; Sady, Vaughan, & Gioia, 2011).
This chapter describes the overall structure of a concussion team, as well as a logical delegation of roles. Rather than learning an entirely new skill set, this process largely requires that school personnel tap into their existing skills—and do the types of things they’re already doing in their jobs—to assist this specific population of students. This chapter highlights the importance of identifying a concussion team leader (CTL)—one person in the building who is responsible for facilitating the concussion team. This person takes the lead in case consultation, educating the school community about the process, and family–school–medical team collaboration. This chapter also includes a discussion of maintaining student privacy through following Family Educational Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) regulations. Finally, it concludes with a reminder to consider how the concussion team model can be created in a way that is sustainable across the school years.
THE CONCUSSION TEAM
The presence of a collaborative team can facilitate coordinated, medically approved, return-to-activity decisions. The team can share information related to the student’s concussion and observations of the student during the school day. School-based personnel can collaborate with the family to develop an appropriate program that will meet the student’s needs. The team can also help explain the plan and rationale for academic adjustments to other school personnel. Additionally, the team is responsible for ongoing assessment of the student’s symptoms and progress toward healing.
A district-wide written policy should clarify procedures. This can help ensure continuity in the processes as team members come and go due to job changes. The core concussion team can ensure that all stakeholders in an individual student’s situation—including the parents and teachers who may not have extensive training or deep understanding of potential implications of concussions—understand the increased risk of further concussions. The team also ensures that multiple people are watching and helping the student. This team helps determine appropriate adjustments to the educational environment and helps inform return-to-school and return-to-play decisions.
Damien
When Damien returned to school, he still had visible injuries from his car accident, including a broken leg. Because he had a visible injury, his team of teachers at the junior high knew that he needed special attention and accommodations. He left classes a few minutes early to avoid the rush of people in the hallways, and a classmate assisted by carrying his books. Damien was given extra time to make up the assignments he had missed during his absence and he received a great deal of sympathy and support from both his teachers and his classmates.
However, the staff at Damien’s school did not know much about concussions and they did not have a concussion team. Further, because Damien was not an athlete, there was no coach, trainer, or athletic director managing a return-to-play protocol.
Damien did not participate in physical education (PE) class because of his broken leg. During his usual PE period, he went to study hall to catch up on missed work—and there was a lot of it. Because he missed school immediately following his car accident, Damien had fallen far behind on his schoolwork. This included pages of math requiring processes he had never been taught and was trying to figure out on his own. In addition to this extra study hall time at school, Damien was spending hours on homework each night, both trying to catch up and trying to keep on-pace with the new assignments and lessons that were coming his way each day. The homework made his head hurt and sometimes even made his heart race with anxiety. Damien’s older brother, Michael, had been driving carelessly and caused the car accident that hurt Damien. Now their parents were upset with Michael and overprotective of Damien. Damien thought the last thing they needed was to hear that he was struggling at school. Damien felt like he was drowning, but he did not say anything to his parents—he did not say anything to anyone.
Once Damien’s bandages and cast were removed, everyone was relieved and expected him to be fine. Although Damien was diagnosed with a concussion while in the hospital, both he and his parents thought it was no big deal—that it was the least of his injuries.
Damien’s teachers were frustrated that he was not keeping up on his school work. His parents scolded him for being lazy and moody. His brother, Michael, accused him of “milking” the extra attention. Damien’s grades started to decline and his friends, who had initially been supportive following the accident, contacted him less and less.
Damien clearly needed a support team at school. A CTL who was aware of the symptoms of concussion could have ensured that appropriate school-based supports were put in place not only for his visible injuries, but also for his invisible concussion. The team could have secured a release of information to talk freely with Damien’s medical providers to obtain sound recommendations for helping him at school. They may have suggested that the study hall period be used for resting rather than for catching up on schoolwork without help—which likely required cognitive exertion that exacerbated his symptoms. The team might have collaboratively designed a plan that allowed Damien to be excused from some of his assignments without penalizing him with lowered grades. This kind of accommodation could have helped decrease his anxiety and prevented his headaches and other symptoms from worsening.
The team could also have been a source of much-needed support for Damien’s family. They were dealing not only with Damien’s injuries, but also with struggles within their family related to his older brother’s careless driving. There was arguing, fear, and blaming within Damien’s family. While the school-based concussion team is not expected to serve in the role of family therapist, it can be an important source of support for the family. It can be tremendously reassuring to the parents to know that educators are “watching out” for their child and implementing appropriate educational accommodations to meet their child’s short- and longterm needs.
TEAM STRUCTURE
Figure 3.1 illustrates the groups of individuals that can comprise an effective concussion team, followed by suggested key members of a concussion team and a description of each team member’s potential roles and responsibilities. All of these team members are encouraged to seek out continued professional development regarding concussions.
The family
Parents and Guardians: Parents need to be both providers and recipients of information; clear communication with medical providers and school personnel is essential. Parents should submit information and instructions from physicians to the school and help their child maintain compliance with recommendations from the medical and academic teams. They should become familiar with their school district’s policy and protocol related to return to school and return to academics. Parents know their children best and are often excellent informants of how their child is “different”following a concussion. Thus, parents are important monitors of their child’s health during the recovery process and the transition back to a learning environment. They should report any concerns to their child’s physician and to the school and follow recommendations from the medical provider related to what the child should and should not be doing at home. Team members can assist parents and guardians by ensuring that they know what a concussion is, the possible effects visible in school, and the importance of following medical guidance.
Figure 3.1. Composition of a school-based concussion team.
Adapted from Nationwide Children’s Hospital (2012a).
Student: Students should participate in the concussion team process to a degree that is developmentally appropriate. They should follow instructions from their medical provider and be made aware of the risks associated with doing too much too soon. Students who have sustained concussions can share with their parents and other concussion team members what symptoms are most bothersome, which ones are getting better, and their perceptions of how things are going with the accommodation plan. The information provided by students is essential in helping the team support the transition back to regular activities. Thus, students should be encouraged to ask for help and to let teachers know if they are having difficulty with symptoms or assignments. They can use a symptom log (e.g., rate symptoms 0–6 to identify severity). Such a log helps track if symptoms are getting better and can help the school and medical team with the treatment and return to academics process. In more general terms, students can receive education on how to prevent future head injuries, can learn how to recognize signs and symptoms of concussions, and can encourage teammates and classmates to report known or suspected concussions. This can help to change the culture surrounding concussions toward one where concussion reporting is not only acceptable, but encouraged.
Academic team members
Teachers: Teachers can help ensure that students are getting the best education possible and follow recommended academic adjustments. Teachers must refer students suspected of having a concussion—for example, one who states he or she had a bad fall the night before and now appears distracted, sluggish, and confused—to the school nurse or other designated personnel to be evaluated for a suspected concussion. After a student is diagnosed with a concussion, his or her teachers are essential for observing the student’s symptoms and recovery trajectory. Teachers are also responsible for implementing appropriate academic adjustments, per the medical provider and/or school concussion team’s recommendations. They may also interact regularly with the injured student’s parents and report daily changes in the student.
School Psychologist: The school psychologist can evaluate the student’s current level of functioning, identify appropriate resources, and facilitate the provision of services. He or she can also assist with ongoing assessment, intervention, and progress monitoring toward a student’s recovery. This may include supporting teachers in monitoring the efficacy of specific academic or environmental adjustments that are part of the student’s return-to-learn plan. The school psychologist can ensure that students diagnosed with concussions do not substitute mental activities for physical ones unless the medical provider has provided written clearance for the student to do so. The school psychologist may be a consultant for prolonged or complicated cases where long-term adjustments or more extensive assessment and educational plans are required. The school psychologist can also assist in training staff about concussion; he or she can teach the signs and symptoms of a concussion and how a concussion may affect a student in school.
School Counselor: The school counselor can help create and disseminate guidelines regarding academic adjustments to the educational team. The school counselor can provide emotional support for both the student and his or her family. After a student’s concussion, parents may become overprotective and restrict previously enjoyed freedoms, such as driving, climbing on equipment, riding bikes, or “rough and tumble”play. All team members—but particularly the school counselor—can listen, validate parents’ feelings and concerns, and work toward finding common solutions and goals. The school counselor also might serve as the CTL, particularly if the building does not have a nurse or if the school psychologist is only in the building on a part-time basis.
Administrator: The school administrator on the concussion team is responsible for ensuring that there is a concussion management team in place; the administrator is also typically responsible for appointing a CTL. The administrator ensures that the district and building-level policies related to concussion management are implemented and followed. This includes ensuring that the concussion management policy is communicated to school staff. The administrator should also coordinate professional development sessions related to concussion management for staff and parents. When a student sustains a concussion, the administrator can help ensure there is coordination of team efforts and that communication among team members is adequate. Further, the administrator can ensure that educators are supported in their provision of supports and services, including excusals from assignments and assessments, schedule adjustments, grade adjustments (working with teachers to complete grade cards and determine on what work grades should be based), and return-to-play guidelines for student athletes. The administrator can provide guidance to staff members on policies and procedures related to emergency care and transportation of students who may have sustained a concussion. For example, if a student is injured at an after-school practice and the parents cannot be reached, the administrator would need to ensure there is a policy in place and clear understanding among staff members about how such situation are managed. Administrators are key team members in encouraging parents to report concerns about their children to appropriate staff members; they should also encourage parents to communicate with medical providers regarding a time frame for any injured child’s return to school. This professional would also be responsible for troubleshooting problems.
Other Academic Personnel: Depending on the school, other academic personnel may have significant involvement with the concussion team. For example, speech language pathologists (SLPs) can help monitor students with concussion and identify changes in how a student is communicating or interacting with others. SLPs might assess students and/or give teachers classroom-based strategies to facilitate students’ expressive and receptive communication. School secretaries might be the first people to see students with concussions stumble into the office after falling during recess. They need to know what to do in such situations to ensure the student receives prompt and appropriate attention. School social workers might serve in much of the same capacity as school counselors.
Medical team members
Physician (or other medical personnel): The child’s physician can describe the injury, severity, and prognosis to the other team members. The physician can also give recommendations and help guide removal of academic supports that may have been part of the recovery process. Because medical providers are governed by HIPAA and school districts are governed by FERPA (see the “Student Privacy”section later in this chapter for more information), it is essential that appropriate releases of information be signed from the outset of the collaboration process to allow bidirectional communication between educators and the medical provider. The medical provider should describe specific symptoms that family members and school personnel should watch out for. He or she should provide a written return-to-activity protocol to follow, or endorse the use of a district-specific return-to-activity schedule. This professional is also typically responsible for providing written clearance for a student athlete to return to play and full activities, including PE class and recess. Teams should clarify their district or state’s qualifications for a medical provider to provide this evaluation.
School Nurse: If a child is injured at school, the school nurse will likely be the person to provide an assessment of whether that student is suspected of having sustained a concussion. This will involve a symptom assessment, an observation for signs, and a referral for additional evaluation if necessary. The nurse can determine if danger signs are present that warrant transportation to an emergency department, or whether the constellation of signs and symptoms warrant the student being picked up by his or her parents and referred to a medical provider for evaluation. The school nurse may also provide parents with written instructions on how to observe their child for danger signs that may warrant emergency care. When a child who has sustained a concussion returns to school, the school nurse can help with symptom monitoring and provide a place to rest during the school day. He or she may also serve as a resource for other school personnel who have questions about the implications of a student’s concussion. This professional can help implement orders from health care professionals and determine if it is appropriate for the student to be in school and whether health-related adjustments need to be continued. The school nurse is essential in collaborating with district administration in the formulation of a concussion management policy. Policies may look quite different from district to district, depending upon the staff and resources available. The nurse can also be a direct liaison to the student’s primary health care provider. He or she may obtain the signed release of information allowing for direct communication to clarify orders or reformulate a care plan. The school nurse may then be the team member responsible for informing district staff members about the student’s return to activity plan. The school nurse will be particularly involved in cases of students experiencing prolonged recovery or who have sustained multiple concussions. He or she may also help student-athletes understand the relationship between their recovery status and the results of neurocognitive tests that are described later in this book. Finally, the school nurse can help implement prevention and education programs by giving staff, students, and parents information on concussion prevention, identification, and management.
Athletic Trainer: The athletic trainer (AT) can be involved in education and awareness training about concussion at the start of a season. If a child sustains an athletic injury, or sustains a nonathletic injury but expects to continue involvement in school sports, the AT can evaluate possible injuries and make referrals to appropriate care providers. The AT can determine if signs and symptoms of concussion warrant transportation to an emergency department or if parents should be referred to the child’s medical provider for evaluation. The AT can also provide parents with written instructions on how to observe the student for complications that may be related to a concussion that indicate emergency care may be warranted. Once a student with a concussion returns to school, the AT can help the school implement the medical provider’s recommendations, facilitate communication among all team members, and review the medical provider’s recommendations with the student. This professional can help monitor ongoing symptoms and assist with coordinating and supervising the return-to-activity process. He or she can also communicate with the school about the student athlete’s ongoing progress. The AT is essential in ensuring that student athletes receive postconcussion care as directed by their medical provider. ATs can also oversee the process of all student athletes taking computerized neurocognitive tests to establish a baseline, retesting after injury, and providing the results to outside medical providers to aid in determining the student’s status and degree of recovery. Depending on district policy, the AT may be the designated individual to review and accept the outside medical provider’s written clearance to allow a student athlete to return to play. The AT would then inform appropriate district staff of the student’s clearance to return to activity.
Athletic team members
Coach: Coaches can be involved in the education and awareness training about concussion at the start of a sports season. The coach can help recognize concussion symptoms in players and remove players who may have sustained concussions from athletic play, including practice and competitions. He or she should remove a student who has sustained a significant blow to the head or body and is exhibiting signs or symptoms of concussion from play. Because the coach may not have witnessed the collision, he or she can receive communication from other team members about a student athlete’s injury. The coach can contact the school nurse or AT for assistance in evaluating and managing a student’s injury. The coach should send students exhibiting any of the danger signs related to head trauma to the nearest hospital emergency department via emergency transport, or follow district policy related to such situations. In less urgent situations, the coach can inform parents of the suspected concussion and refer them to their medical provider, with written information on concussions and the district’s concussion management policy. He or she can also communicate with school personnel about the student’s injury and subsequent progress upon return to school. The coach should also ensure that a student who was diagnosed with a concussion does not return to participation in athletic activities until he or she has received written clearance from a qualified medical professional.
Athletic Director: The AD is responsible for overseeing the athletic department’s concussion team plan. This includes development and management of safety and response policies; education of athletes, coaches, and parents; and equipment management. The AD should be aware of district policies regarding concussion management and act as a liaison between coaches and district staff. The AD will likely be responsible for ensuring that appropriate information is provided to student athletes, parents, and coaches at the outset of each sports season and that the appropriate consent forms are signed for athlete participation. This person can offer additional educational information and programs related to concussions and sports safety. The AD must inform the school nurse, the AT, and the CTL of any student suspected of having a concussion. He or she can then ensure that the student is not permitted to participate in athletic activity, practice, or play until they secure a written clearance from a qualified medical professional is received. The AD is also responsible for making sure coaches know and understand district protocols related to emergency medical transport of students who are injured during interscholastic athletic events, including practice. The athletic director (AD) is advised to keep yearly logs of concussed athletes who play multiple sports. Finally, the AD must enforce district concussion policies, including training of athletic personnel and return to play protocols.
PE Teacher: The PE teacher can help ensure that students are following recommended guidelines for physical activity following concussion. The PE teacher can also find alternative ways for such students to be involved in the lessons or activities. He or she can assist with observing a student’s symptoms and recovery trajectory. This professional would report any students with observed signs or reported symptoms to the CTL.
THE CTL
The CTL or case manager will serve as the primary point of contact for all team members, including the student and his or her parents/guardians. This person will be the primary advocate for the student’s needs. He or she will also convene team meetings, ensure adequate communication among team members, and facilitate a seamless implementation of an accommodation plan. Other responsibilities will likely include overseeing the return-to-learn process and getting a release of information (ROI) document in order to speak with the student’s physician about medical care and the improvement trajectory.
Every school and district is different; therefore, there is flexibility in overall team membership and in who might be appointed as the CTL. Depending upon the roles and responsibilities of different professionals in the school, the CTL might be the school psychologist, school nurse, school counselor, an administrator, or someone else. The designated individual should be organized, have excellent communication and collaboration skills, understand the importance of data-based decision making and progress monitoring, be willing to learn, and be in the school building most days. In many cases, the logical choice is the person who serves as the building’s Section 504 or Intervention Assistance Team Coordinator, as many of the same skills can transfer to the CTL role.
At the onset of the school year, the CTL should be made known to everyone within the school community, including parents, teachers, coaches, and athletes. This lets everyone know to whom concussive injuries should be reported. Depending upon the size of the district and the extent of support staff available, the school concussion team may elect to have two leaders: the CTL, who would also serve as the academic leader (AL) or medical leader (ML), as well as a second individual who would take the lead role in academic or medical concussion management (Nationwide Children’s Hospital, 2012b).
Exhibit 3.1 shows three sample high schools that have concussion teams comprised of different professionals. The team members listed for each school are consistent members across the school year. The student, parent(s), and physician obviously change for each case.
In the first example in Exhibit 3.1, if Kennedy High School’s CTL is the school nurse, that person would also serve as the ML, and the designated AL is someone from the “academic team”—in this case, the school counselor. However, at Jefferson High School the CTL is the school psychologist, who also serves as the AL. In this school, the second leader is someone from the medical team; the nurse’s aide serves as the ML.
In schools that do not have sufficient resources to split the medical and academic duties, the CTL may be responsible for both the medical and academic assessments and accommodation coordination. This is generally the school nurse, school psychologist, school counselor, or an administrator. For example, Washington High School is a smaller, rural school with few support services. While related service personnel are members of the concussion team, the school has only one designated leader.
EXHIBIT 3.1
Sample Concussion Team Structures With One Versus Two Leaders
TWO-LEADER MODELS |
ONE-LEADER MODEL |
|
KENNEDY HIGH SCHOOL |
JEFFERSON HIGH SCHOOL |
WASHINGTON HIGH SCHOOL |
CTL/ML: School nurse |
CTL/AL: School psychologist |
CTL: School administrator |
AL: Lead school counselor |
ML: Nurse’s aide |
|
Members: Principal, AD, athletic trainer, all other school counselors (one per grade level) |
Members: Assistant principal, speech-language pathologist, lead PE teacher, AD |
Members: School counselor, district nurse, head football coach |
AD, athletic director; CTL, concussion team leader; ML, medical leaders; PE, physical education.
CONCUSSION MANAGEMENT PROCESS
A number of models describe a process of concussion management within a team framework. This can be individualized to meet school and district needs. In general, the first step is to inform the school community that there is a specific process to be followed for each school. This information should be shared with district personnel, students, and families. Following is some simple, suggested language that can be modified based on district need. This type of memo can be shared in school newsletters, as e-mail blasts, or on district websites:
Dear Staff and Parents:
[Insert name of school] is implementing a concussion team model to help students who have sustained concussions safely return to school. Team members include: [insert names of concussion team members and their professional roles within the school].
If you know or suspect your child has sustained a concussion, please contact [insert concussion team leader’s name and contact information] right away. The team can then develop a plan of academic adjustments to help your child when he or she returns to school.
Sincerely,
[insert name and title of school principal and/or concussion team leader]
Then, once a concussion case is confirmed and the team has met with the family to devise an academic accommodation plan, a more extensive letter can be distributed to the student’s teachers. It might read something like this:
Dear [staff member name or role],
[Insert student name] sustained a concussion on [date]. We ask that you assist with [his/her] concussion management and recovery.
Each concussion can cause different symptoms. Some symptoms may appear right away and some may develop over time. Some students recovering from a concussion may need to stay home from school to rest for a few days before returning to school. Most students who have sustained concussions will be better within a few weeks, but some can take months to recover. Many return to school while they still have some symptoms and managing these symptoms appropriately can help with recovery. Common signs and symptoms of concussion include:
Signs (observed by others) |
Symptoms (reported by the student) |
|
Physical
|
|
Emotional/Mood
Sleep
|
A student who has sustained a concussion needs to rest the brain following injury. This includes avoiding bright lights and loud noises (including dances, sporting events, TV, loud music, video games, smartboards, and computers). Cognitive activities such as reading and problem solving may need to be adjusted.
Attached is an Academic Adjustment Plan that indicates school-based adjustments selected by the concussion team and/or the student’s physician for optimal healing based on this student’s symptoms. Please be flexible and understand healing takes place at different rates. Please contact [concussion team leader name and contact info] if you have any questions or to report any worsening of symptoms.
Thank you.
[name and role]
Concussion Team Leader
Source: Adapted from ORCAS’ Brain 101: The Concussion Playbook.
The following concussion team process (Exhibit 3.2) is adapted from Nationwide Children’s Hospital’s Concussion Toolkit (Nationwide Children’s Hospital, 2012b). A key benefit of the process is that it is flexible, allowing it to meet the needs of districts of different sizes with varying demographics.
Figure 3.2. Concussion team process. Adapted from Nationwide Children’s Hospital. (2012a).
1. Step 1. Concussion reported. Step 1 allows for the possibility that a concussion may be reported to anyone within the school setting. A parent might call the school nurse. A student might alert the teacher. A coach might tell the AD. Any concussions reported to anyone within the school setting are to be reported to the CTL as soon as possible.
2. Step 2. Contact student and family. The CTL and/or the concussion team will meet with the student upon his or her return to school, even if the return involves a partial day. For younger students, this initial meeting will also involve the parents. For older students, parents can be included, but this is not required to carry out the remaining steps. The CTL will explain his or role, provide contact information, and describe next steps in the process. The CTL will also describe what is expected from the student and family, including honest communication, adhering to recommendations, and the two-way sharing (with a signed release) of information and documentation with the physician. This initial contact is essential for ensuring good communication with—and compliance from—the student and his or her family.
3. Step 3. Assess medical needs. This step involves gathering documentation, if available, from a physician and/or AT. This documentation may specify recommendations concerning restrictions from cognitive and physical activity, as well as recommended adjustments to the learning environment. Sometimes, a school team knows that a student has sustained a concussion, but no specific recommendations are available from a medical provider. In such cases, the CTL or designated ML, such as the school nurse, should conduct a symptom assessment to determine whether the concussed student will benefit from being at school, whether there should be a modified school day, or whether any attendance at school is likely to be counterproductive. The Concussion Symptom Tracking Log (see Chapter 4) can assist with this assessment. Students whose symptoms are severe will likely need to be sent home. However, if symptoms are mild and manageable, and are not exacerbated by being at school, the process can continue to Step 4.
4. Step 4. Assess academic needs. Once a student is back to school for partial or full days, the school team can begin to implement any necessary and appropriate academic adjustments. The medical provider may send the parents or the school recommendations for academic adjustments. Such recommendations should be incorporated into a specific, written plan. If no recommendations are available, or if the recommendations are vague or no longer relevant (due to rapid healing that can take place after a concussion), the CTL or designated AL should assess the concussed student’s academic needs. The Classroom Concussion Assessment Form and other information found in the next chapter can assist with this process.
5. Step 5. Distribute adjustments. The plan for adjusting the learning environment and academic expectations is then distributed in writing to the student’s teachers, family, and (if applicable) athletic staff by the CTL. Updates to medical information are included as well. Chapter 6 contains detailed information on how to map the assessed academic needs onto appropriate school-based adjustments.
6. Step 6. Determine reassessment. The CTL will identify an appropriate timeline for reassessment of needs to ensure that adjustments are not maintained for an unnecessary length of time. This can also help team members determine if new adjustments may be required to address new symptoms or issues. This is determined based on data and feedback from the team; the team should go back to Steps 3 or 4 as needed. It is recommended that the team reassess medical and/or academic needs when:
New physician documentation arrives dictating a new course of action
Symptoms have changed (and therefore the prior assessment needs to be altered)
Symptoms have resolved and are no longer a barrier to school participation or attendance
Teachers or parents identify problems in the current plan that are not being adequately addressed
Once the reassessment is complete, the CTL will document the results and return to Step 5, notify relevant parties of any changes to the plan, then continue to Step 6, identify appropriate time frame for reassessment (Nationwide Children’s Hospital, 2012b).
Ben
While Ben’s recreational league football coaches and parents could have used more education about concussion causes, signs, and symptoms prior to the start of his football season, his elementary school’s concussion team had a coordinated and proactive response.
Ben’s mother took him to the emergency department the night after he sustained a significant blow to the body during his football game. He was diagnosed with a concussion and received general recommendations upon discharge, including that he “avoid physical activity and reduce cognitive demands (reading, texting, computer use, video games, etc.).” The doctor indicated that school attendance and after-school activity may need to be modified to avoid increasing symptoms. The written discharge instructions also suggested that Ben’s parents contact his physician or another physician who was knowledgeable about concussion management after leaving the emergency department. While these are good general recommendations, Ben’s parents decided that he didn’t need to see another doctor and they would just let him rest.
Ben stayed at home from school for 2 days, mostly watching television and listening to music with his headphones. Because those activities were not specified as off-limits on the emergency department discharge form, his mother thought it would be fine. After the second day, Ben’s mother could not miss any more work and Ben’s father was traveling out of town, so Ben went back to school. Ben’s mother sent his teacher, Mr. Stevens, an e-mail letting him know that Ben was diagnosed with concussion but now seemed well enough to go back to school.
Ben’s school had a concussion management team in place. Mr. Stevens knew the protocol was for him to immediately contact his school’s Concussion Team Leader (CTL), Ms. Tippins. Ms. Tippins immediately contacted Ben’s mother and asked her to sign a release of information (ROI) to allow her to receive and review Ben’s medical evaluation and speak with his doctor. When Ms. Tippins learned that Ben had only been seen in the emergency department, she suggested to Ben’s mother that she follow up with a concussion specialist and gave a few recommendations of local physicians. Ms. Tippins emphasized that Ben would benefit from having a qualified medical provider indicate when he could safely return to football practice and play.
“Part of my role is to make sure that Ben’s teacher and everyone else here at school understand that Ben has had a concussion and may need a bit of time before he’s feeling better.” Ms. Tippins told Ben’s mom. “I’ll be checking in with you over the next few weeks to see how Ben seems at home and to let you know what we’re doing at school to make adjustments while Ben’s concussion heals. Now, can you tell me how he slept last night?”
Ms. Tippins proceeded to ask Ben’s mother specific questions regarding Ben’s symptoms using a list of possible symptoms to see if she had observed any of them or if he had complained to her of any. She also asked a few key questions to help the team formulate an appropriate plan of academic adjustments for Ben. She then met with Ben to evaluate which symptoms were present and how intense they were. The outcomes of this assessment and a copy of his academic adjustments can be found in the chapters on concussion assessment (Chapter 4) and Adjustments to the School Environment (Chapter 6).
EDUCATING THE SCHOOL COMMUNITY
Anyone responsible for the student both during and after school hours—including bus drivers and babysitters—should receive information from the concussion team regarding how they can best help the student. They can also help monitor symptoms during recovery by reporting academic, behavioral, or emotional concerns to the CTL.
Educators often deal with situations involving students making excuses for why their schoolwork is not finished. This can lead to some skepticism when someone is asking them to make exceptions for students who have sustained concussions, particularly because this is an invisible injury. Thus, it can be difficult for some teachers to understand if a student is being truthful when he or she continues to complain of symptoms or when a student’s parent or doctor reports that a child is taking a long time to heal.
The school-based concussion team can be instrumental in educating the entire school community—teachers, administrators, support personnel, parents, and students themselves—about what a concussion is and what an injured student might be experiencing. Having teachers who are sympathetic and who understand the needs of a concussed student can help provide reassurance to a student that he or she will not fail classes because of missed work or missed days of school. This, in turn, can decrease the student’s stress and thus facilitate recovery. By pulling together a team of caring professionals, the CTL can ensure that everyone involved in the student’s life—parents or guardians, coaches, teachers, health care providers—is getting the same information and is hearing a consistent message.
More information on training for the school community, including parents and teachers, can be found in Chapter 7.
WORKING WITH PARENTS
It is crucial to involve the family in the transition process; the entire family may be affected by the injury. Parents may become overprotective and restrict previously enjoyed freedoms (e.g., driving to school, bike riding, climbing on playground equipment). This is often extended to siblings.
It is important that school-based members of the concussion team involve parents as equal partners and participants as team members. It is important to listen, validate parents’ feelings, avoid defensiveness, recognize fear and frustration, focus on solutions, and work together toward common goals.
Julia
Julia wanted to resume playing soccer while she still had concussion symptoms. She also wanted to push through completing her school assignments so they would not continue looming over her head. In a meeting with the concussion team, Julia’s mother was upset.
“This has continued for too long! She’s still not better! I just want her on complete bedrest until her symptoms are totally gone.”
“There is no way that is happening,” muttered Julia.
“Generally, what we see is that students heal the fastest when there is a balance between rest and exertion,” explained the athletic trainer. “We’d love to see Julia back on the soccer field, but you’re right that she needs more rest from activities before she can be cleared for that. At the same time, most studies have shown that if someone with a concussion just goes into a dark and quiet room without any stimulation, their symptoms actually take longer to get better.”
“We want to help Julia find that balance,” added the school counselor. “I’m also concerned that Julia has seemed very down since her last concussion.” She looked at Julia. “You seem to be pulling away from your friends and social activities. It would be great if we could find some things that you enjoy that don’t involve playing sports or being around a very stimulating environment.”
“There’s nothing,” Julia shook her head.
“She wants to be on the move. She always has,” Julia’s mother said. “She likes loud concerts and mountain climbing and going to the movies—3D with surround sound! There is nothing she really enjoys that doesn’t involve a lot of action and noise. But it all makes her symptoms worse, especially the headaches.”
“You’re absolutely right that those things all might make her concussion symptoms worse and prolong her recovery,” validated the school nurse. “But maybe some of those things can be tempered a bit. Like instead of loud concerts, you could listen to acoustic music at a mellow coffee shop.”
“Yeah,” Julia’s concurred. “I like that kind of music, too. But coffee makes my head hurt.”
“Try herbal tea,” suggested the school nurse.
“Or instead of mountain climbing you could walk in the woods, and instead of loud 3D movies, maybe you could find good movies to watch at a lower volume at home. That way if it makes your symptoms worse at all, you could turn it off and come back to it later,” suggested the athletic director.
Julia’s mom laughed, “She does seem to like the older movies from the 1980s more than a lot of the newer ones.”
“And maybe if you do that, a couple of friends from the soccer team could come over to watch with her,” added the school counselor. “Not a big crowd, but just a way to keep that support system going.”
“That’s a good idea,” said Julia’s stepfather. “I’ll try to get a few of those movies for her.”
“And we want the two of you,” the school nurse nodded at Julia’s mom and stepfather, “and you,” she nodded at Julia, “to be sure to tell us if there are any changes in your symptoms, for better or for worse, based on these new adjustments we’re putting into place at school. Now, let’s go over these possibilities …”
In Julia’s case, the team did a nice job of involving both Julia and her parents in a dialogue of problem solving and support. They validated what the “family team” was experiencing and incorporated their input and suggestions, all of which were very important in structuring a plan that made sense for this student.
STUDENT PRIVACY
The benefits of a team approach to concussion management are innumerable. At the same time, any time personnel discuss a student’s medical condition and academic performance—particularly when there are electronic communications and multiple forms of data tracking that student’s progress—school personnel must be mindful about student privacy.
Health Insurance Portability and Accountability Act
Information about a student’s health is protected by the Health Insurance Portability and Accountability Act (HIPPA) of 1996. HIPAA generally applies to protected health information in nonschool settings. Such health information includes that which is related to treatment, assessment, and past, present, or future health conditions. HIPAA requires that medical information not be disclosed to anyone besides the parent or guardian unless otherwise specified in writing. Thus, a signed ROI is important to allow the school to receive and discuss medical information related to a concussion with a student’s health care provider. An exception to this is that the HIPAA privacy rule allows health care providers to disclose protected health information about students to school nurses for treatment purposes, without the authorization of the student or the student’s parents. This might occur in cases where the school nurse administers students’ medication or tends to their other health care needs at school.
Medical providers will likely have their own forms that they also want completed and signed. Such forms generally ask the parent to sign authorization for the health care provider to disclose protected health information to the school. The form may specify that the release of information covers the period of health care for a specific period of time or for all past, present, and future periods. The form may also allow the respondent to authorize the release of the student’s complete health record or for the complete health record excluding specific exceptions.
Family Educational Rights and Privacy Act
Information on a student’s academic record is protected by the Family Educational Rights and Privacy Act (FERPA; 1965b). FERPA protects students’ personal information, including that which is related to their name, address, social security number, educational records, and health records obtained by an educational agency that have become part of an educational record. For example, a student’s immunization record maintained by an educational agency or the school nurse would be protected by FERPA. Additionally, records maintained by schools related to special education, including records on services provided to students under the Individuals with Disabilities Education Improvement Act (IDEA) of 2004, are considered educational records under FERPA.
All schools that receive funding from the U.S. Department of Education are required to adhere to FERPA regulations. As such, they must secure student educational records against intentional or unintentional release. Under FERPA, parents have the right to inspect and review their child’s educational records until their child reaches the age of 18. At that time, the rights transfer to the student. These records cannot be shared with a third party without written parental consent (or the student’s consent if he or she is over 18) unless disclosure meets one or more specific exceptions to FERPA’s general consent requirement. One such exception allows schools to disclose a student’s health and medical information and other educational records to teachers and other school officials, without written consent, if the school officials have “legitimate educational interest” in accordance with school policy. For example, a school counselor who is helping plan a student’s next year of classes could review the student’s previous coursework without explicit written parental permission.
Another permissible disclosure without explicit written consent is release of records to appropriate parties in connection with an emergency, if knowledge of the information is necessary to protect the health or safety of the student and other individuals (U.S. Department of Health and Human Services and U.S. Department of Education, 2008). For example, there was considerable debate in the academic community following the Virginia Tech shootings about the university’s counseling center, campus police, and academic departments all having knowledge about the shooter’s violent tendencies. However, each of these departments failed to share critical information about his issues because they believed that doing so violated FERPA. The emergency exception in FERPA may have allowed for sharing among Virginia Tech departments about the shooter’s conduct that demonstrated he posed a risk to himself and others, if the threat was imminent (Chapman, 2009).
Staff members should be regularly reminded to only discuss information that is necessary to manage the student’s situation. They must also understand how to appropriately communicate what is involved in a student’s plan in a way that maintains student privacy. This includes specific directives from the school district regarding electronic communication and the secure storage of student records.
Carly
When Carly was bothered by the bright lights and loud noises the day after falling from the monkey bars, Carly’s teacher, Mrs. Lang, went into the office. After a parent volunteer who was making copies left the room, Mrs. Lang asked the attendance secretary for more information about Carly’s fall and subsequent behavior in the office the day before.
The nurse was in the office that day, so Mrs. Lang relayed the situation to her. The nurse then pulled Carly’s health form to see if there were any reports of a previous history of concussions and asked Mrs. Lang to send Carly down to see her.
While the school’s failure to inform Carly’s parents about her fall from the monkey bars the day of the injury was a significant misstep, they handled communication about the incident the next day appropriately. Because the secretary had seen Carly immediately after the injury and the nurse was knowledgeable about concussions, it was appropriate for both of them to discuss this situation with Carly’s teacher. People were involved on a “need to know” basis. Mrs. Lang did not discuss Carly’s accident in front of a parent volunteer and the school nurse accessed a medical record that was part of a school record because there was a legitimate educational interest.
The U.S. Department of Education and the U.S. Department of Health and Human Services published a joint guidance document on the application of FERPA and HIPPA of 1996 to student records (www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-hippa-guidance.pdf), which can provide information to school teams on their rights and restrictions in terms of accessing and sharing student information.
SUSTAINABILITY OF THE MODEL
A written procedure needs to outline a coordinated communication plan among appropriate staff to not only ensure that postconcussion management plans are implemented and followed for individual students, but also that the team model is sustained from year to year. It is important that school personnel make sure that the protocol is not depending upon a specific person or role. It is also essential that the concussion team model include a procedure for periodic review of the team structure and the concussion management policy, given the changes in concussion protocol that grow out of research.
REFERENCES
Chapman, K. (2009). A preventable tragedy at Virginia Tech: Why confusion over FERPA’s provisions prevent schools from addressing student violence. Public Interest Law Journal, 18, 349–385.
Family Educational Rights and Privacy Act, as amended. Codified at 20 U.S.C. § 1232g (1965a).
Family Educational Rights and Privacy Act Regulations. 34 C.F.R. Part 99 (1965b). http://www2.ed.gov/policy/gen/guid/fpco/ferpa/index.html
Halstead, M. E., McAvoy, K., Devord, C., Carl, R., Lee, M., Logan, K., … Council on School Health. (2013). Returning to learning following a concussion. American Academy of Pediatrics, 132(5), 948–957. doi:10.1542/Peds.2013-2867
Health Insurance Portability and Accountability Act of 1996, as amended. Codified at 42 U.S.C. § 1320d et seq. and § 300gg; and 29 U.S.C. § 1181 et seq. P.L. No. 104–191, 110 Stat. 1938 (1996).
Individuals with Disabilities Education Improvement Act, 20 U.S.C. § 1400 (2004).
McAvoy, K. (2011). REAP the benefits of good concussion management. Centennial, CO: Rocky Mountain Sports Medicine Institute Center for Concussion. Retrieved from: http://rockymountainhospitalforchildren.com/service/concussion-management-reap-guidelines
Nationwide Children’s Hospital. (2012a). A school administrator’s guide to academic concussion management. Retrieved from http://www.nationwidechildrens.org/concussions-in-the-classroom
Nationwide Children’s Hospital. (2012b). Concussion toolkit. Retrieved from http://www.nationwidechildrens.org/concussion-toolkit
ORCAS. (2013). Staff notification letter. Brain 101: The concussion playbook. Retrieved from: http://orcas-sportsconc2.s3.amazonaws.com/files/h_staff_letter.pdf
Sady, M. D., Vaughan, C. G., & Gioia, G. A. (2011). School and the concussed youth: Recommendations for concussion education and management. Physical Medicine and Rehabilitation Clinics of North America, 22(4), 701–719. doi:10.1016/j.pmr.2011.08.008
U.S. Department of Health and Human Services and U.S. Department of Education. (2008). Joint Guidance on the Application of the Family Education Rights and Privacy Act (FERPA) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA) to Student Health Records. Retrieved from www2.ed.gov/policy/gen/guid/fpco/doc/ferpa-hippa-guidance.pdf