https://orcid.org/0000-0002-9113-7875
ABSTRACT
Objective
Examine how demographic and injury factors impact identification and management of concussion in students.
Methods
Prospective observational cohort. Pre-K – 12th grade students within a large, urban school district reported to school with concussion during 2015–2019. Participants were grouped into Elementary/Middle School (E/MS) and High School (HS) and compared by sex, concussion history, injury setting and mechanism, time to medical evaluation and clearance, absences, and recommended accommodations.
Results
154 E/MS and 230 HS students reported to school with physician-diagnosed concussion. E/MS students experienced fewer concussions at school and from sports than HS. More E/MS males than females sustained concussions, while this difference was reversed for HS. Time-to-evaluation was longer for E/MS, specifically female E/MS students and those injured outside of school. E/MS males were cleared more quickly than females. In contrast, no differences were found between sexes for HS by injury setting, mechanism of injury, or management factors.
Conclusion
Differences observed in E/MS students by demographic and injury factors are not observed in HS students. Younger students, particularly females or those not injured in school or sports, may be at risk for delayed identification and prolonged time to clearance. Future research should further characterize concussion management in E/MS children.
Introduction
Concussion accounts for an estimated 75% (Citation1,Citation2) of the more than 1.8 million children who experience a TBI in the United States annually (Citation3). Yet, research focusing on concussions in young people primarily examines those who are in high schools and participate in organized sports (Citation4) – with a focus on male, helmeted sports (Citation5–7). A substantial number of youth experience concussions outside of organized athletics (Citation8) and report to their pediatrician for initial medical care or are monitored at home (Citation9), resulting in limited data about those not injured during organized sporting activities. This population may prove particularly challenging for schools to identify and manage. The Centers for Disease Control and Prevention (CDC) recently published clinical practice guidelines (Citation10) and delivered a report to Congress (Citation11) specifically highlighting the need for improved understanding of how sex and developmental stages impact concussion experiences in children, and how medical and educational systems can support return to activity and reentry to school (Citation8,Citation12).
As children advance in school, sports-related activities become the most common injury mechanism for concussion, shifting away from falls, other recreational activities, and assault (Citation8). All 50 states now have concussion education requirements for coaches, students, and parents, as well as return-to-play laws describing safe return to sport. But, children who experience their injury outside of school-sanctioned sports, physical education (in some states), and younger students are rarely covered by these return-to-play laws (Citation13). Therefore, younger children who experience concussion and those that occur during non-school-sanctioned sports may be at the greatest risk for being missed by school-district concussion protocols, and their parents or guardians may not receive concussion education (Citation13). These gaps may result in young people returning to activities before they are ready, having inadequate return to learn supports, and leaving them vulnerable to repeated concussion or complicated recoveries (Citation14,Citation15).
As educators and medical providers recognize the importance of safely and effectively returning students with concussion to learning, not just to sports (Citation16), there is a need to understand how school systems are identifying and managing students with concussion, regardless of age or injury mechanism (Citation17). Additionally, because research shows that concussion rates for females are higher in comparable sports (e.g., baseball/softball) than males (Citation18–20), there is a specific need to examine how sex differences intersect with concussion management. Given these issues, we describe patterns of concussion identification and management for male and female students across all grades within one large school district from 2015 to 2019.
Methods
This prospective observational cohort study was reviewed by the public-school district’s Institutional Review Board and determined exempt. Data was collected from all 21 schools in a single public-school district in Connecticut during the 2015 to 2019 academic years. Concussion management in the district is based on state policy (Citation21) which bases eligibility on the CDC definition of concussion.
Participants
Participants included students in grades pre-kindergarten – grade 12 who received a diagnosis of concussion from a medical provider and reported with documentation to their school nurse. The school district serves 11,700 children and includes one pre-school program, 12 elementary schools (grades K to 5), 4 middle schools (grades 6 to 8), 1 parochial school (grades K to 8), and 4 high schools (grades 9 to 12). This school district (27.7% white) reports 59% of students are eligible for free/reduced-price meals and 14.5% of students receive formal special education services (Citation22). In elementary, middle, and high schools, 52% of students are male (Citation23).
Data collection
Per district policy, students with documented concussion are managed through school nurse offices. Regardless of injury setting, students can only receive a diagnosis of concussion from a physician. All students must submit a physician’s letter to the school nurse to return to school after concussion. For students identified by an athletic trainer (AT), ATs notify the school nurse, who in turn ensures that confirmation of the concussion diagnosis is made by a physician. Full-time nurses at each of the 21 district schools documented each student concussion using a secure database. Data sources included school documented absences related to the concussion and two physician letters. The first physician letter detailed the date of evaluation, confirmed the diagnosis of concussion and injury mechanism, stated any history of concussion, and provided any recommendations for accommodations. The second physician letter provided the date the student was cleared for return to full academic and physical activity and discharged from medical care related to the concussion. At this time point, accommodations were discontinued, and students could return to athletic activity. For those engaging in sports managed by an AT, the return to sport progression would begin under their guidance.
Before data collection commenced, the primary investigator (KS) provided training to all school nurses regarding study procedures and training occurred annually for the duration of the study. Procedures were first piloted during the 2014–2015 school year to confirm fidelity of data entry and to ensure that all relevant data was captured from available documentation. Data collection occurred between Fall 2015 and Spring 2019. Data sharing and analysis occurred with deidentified data only.
Main outcome measures
Data collection captured student demographic characteristics along with injury-related details and accommodation recommendations from physician letters. Accommodations were coded into five categories describing limits or adjustments to academic activity, physical activity, need for an In-Home Care Plan, a 504 Plan, or homebound tutoring. Time to evaluation (TTE) by physician was calculated as the difference in days between date of concussive event and date of concussion evaluation and diagnosis provided in the physician letter. Time to clearance (TTC) was similarly calculated as the difference between date of injury and date of physician recommendation for full return to academic and physical activity. Setting of injury was grouped into one of the following categories: school-related concussions (ScRC) or non-school related concussions (NScRC). ScRC was further sub-classified into: (1) during official school sports participation and (2) within school (not during official school sports, but including recreational activities like physical education or recess). NScRC was further subclassified into: (1) during recreational and non-school sanctioned sports, (2) motor vehicle crashes (MVC), and (3) other (including falls, being struck by objects, and mechanisms not otherwise covered).
Statistical analysis
Participants were grouped into an Elementary and Middle School Group (E/MS, Grades PreK–8) and High School (HS, Grades 9–12) because previous research suggests they report different school-related impairments and different management challenges (Citation24). Normality of main dependent continuous variable (TTC) was assessed using Shapiro–Wilk test. Since it was not normally distributed (p< .001), continuous variables were compared using non-parametric Mann Whitney U Test. Categorical variables were compared using χ2 test. Although district policies were stable across the four years of data collection, to examine for possible changes in concussion management practices over time, academic year was a priori identified as a confounder. Kaplan–Meier survival analysis was performed to compare TTC between E/MS and HS and Cox proportion-hazard model was used to control for year of injury. To address sex differences, we separated E/MS and HS by sex and compared females to males at each school level separately. Finally, the total sample was grouped by setting of injury (ScRC versus NScRC) and mechanism of injury, and continuous variables were compared using Kruskal–Wallis Test. A p-value of .05 was considered significant. Statistical analyses were performed using SAS Version 9.4.
Results
A total of 384 students in the school district reported having a concussion during the 2015–2019 academic years (E/MS: n = 154; HS: n = 230). Group-wise demographics and outcome variables are presented in . There was a significantly higher proportion of females sustaining concussions in the HS group, whereas there was a higher proportion of males in the E/MS group. The students within the HS group also reported a greater number of previous concussions, as well as a higher incidence of ScRC, with the majority occurring during school sport participation. Although the HS group had their concussions diagnosed more quickly than E/MS students (indicated by a shorter TTE), HS students required accommodations for a significantly longer duration, reflecting a longer TTC and recovery timeline than the younger students. Kaplan Meier Survival Analysis comparing TTC is presented in and Cox proportion-hazard test shows that this finding was not significantly affected by data collection year (X2 = 7.08, p= .069).
Table 1. Student demographics and management by school
Figure 1. Kaplan Meier Survival Analysis comparing duration of accommodations required between Elementary/Middle School and High School students with concussions.
presents concussion identification and management data for female and male students in the E/MS group. More male E/MS students had a previous concussion than female E/MS students. Male E/MS students also had a higher proportion of concussions sustained during recreational sports than female E/MS, whose predominant cause for NScRC were non-sport related activities. Although female E/MS students’ TTE was more than twice that of male E/MS students, this difference did not reach statistical significance. There were no differences in full day absences between males and females in the E/MS group; however, females were recommended to receive accommodations for significantly longer than males, as indicated by longer TTC. presents concussion identification and management-related data for female and male students in the HS group. No significant differences are seen in any of the concussion management variables for these older students. Combined limited physical and cognitive activity were the most common accommodations recommended for both groups. Formal accommodations or services through 504 plans or IEPs were rare.
Table 2. Sex differences in Elementary/Middle School concussion management
Table 3. Sex differences in High School concussion management
Lastly, presents differences in concussion management and accommodations between students who sustained ScRC versus NScRC. Students with NScRC had a significantly greater TTE compared to those students with ScRC. There were no differences seen in TTC or number of full day absences required between NScRC and ScRC. When comparing concussions by causes, NScRC sustained during non-sports activities had the longest TTE, but concussions caused by MVCs had the longest TTC compared to any other causes.
Table 4. Differences in concussion management for ScRC versus NScRC
Discussion
In this study, we examined characteristics of students with concussions identified and managed in one large school district across a four-year period. We found that the demographics of students sustaining concussions shifted as children aged. More males than females were identified in early grades, but this pattern reversed for students in HS. E/MS students experienced more NScRc than ScRC. Male E/MS students were cleared for return to full academic and physical activity 10 days before their female peers. In High Schoolers, no such differences were found; female and male concussion management factors resembled each other across all comparisons. Consistent with past research (Citation12,Citation17), our findings suggest that concussion identification and management protocols are better designed to meet the needs of students at the HS level, but less well adapted to younger students. Younger students are more likely to be injured outside of school and far less likely to be injured playing school sports (Citation8), and these two factors may impact access to school concussion resources. In line with the most updated guidelines on the management of concussion in children (Citation10,Citation25), most students received recommendations for accommodations to support their return to school and reported few absences, indicating that they were attending school during recovery.
Identification of students with concussion
Consistent with previous reports that mechanism of injury shifts over time (Citation8), children in the E/MS sample were more likely to sustain their concussion from non-sport activities. HS students were most likely to experience concussions from sports, and more specifically, official school sports. Because many HS students sustained concussions in school sports, the injuries were more likely to have been witnessed by coaches, teammates, or ATs, and return-to-play protocols enacted to ensure proper reporting and medical clearance. TTE was faster for HS students than E/MS students, but injury mechanism may be the more important factor than age, as non-sport injuries occurring outside of school had the longest TTE and the greatest variability. Variability in TTE was greatest for children with NScRC, specifically in non-sport activities. These injuries may be particularly challenging for school systems to identify, as it requires that parents or students share medical reports of injury, or that an agreement be in place between educational and medical facilities to communicate about the health and needs of students (Citation26,Citation27). Although this district used both of these strategies, most school systems rely on students or parents reporting injuries upon return to school (Citation28), which likely results in underreporting both from the injury not being communicated to schools along with missing injuries when families do not seek medical care (Citation29).
Sex and age differences
Fewer females reported concussions than males in E/MS, but this pattern reversed in HS. Females experience concussion at a higher rate generally than males (Citation20), but previous research also indicates that pediatric injuries differ by sex and age (Citation30). Findings from this study suggest that age is an important factor in understanding how sex impacts concussion. Compared to females, more E/MS males experienced concussion and were more likely to sustain their injuries from recreational sports outside of school. E/MS females on average took longer to receive a diagnosis of concussion than males, but this did not reach statistical significance. Longer TTE is known to be a predictor of recovery timeline (Citation31), and E/MS females also had a longer TTC than males. This identification gap may be a result of females being injured in activities with less monitoring or concussion awareness, but highlights the need for continued research into management across ages and sex (Citation8,Citation17).
For HS students, we observed no differences in TTE timelines by sex, and both male and female students were most likely to be injured while playing school sports. Differences in concussion history and TTC seen in the younger group also disappear, leaving the experience of concussion and care management as quite similar for both male and female HS students. This is in stark contrast to the E/MS group, and confirms prior research indicating that standardized methods for concussion identification and management are specifically needed at the E/MS levels (Citation12,Citation17).
Female E/MS students and both male and female HS students reported an average TTC of more than 1 month to be cleared for full academic and physical activity. Recent CDC guidelines describe children as needing between 1 and 3 months for recovery (Citation10), and the most updated consensus guidelines for sports concussion suggest 4 weeks for symptom resolution in adolescents (Citation25). Our results are largely in line with these and other recent reports (Citation31–34), although using TTC as a proxy for recovery is imperfect. Students may have experienced resolution of symptoms, and then scheduled a follow-up appointment with their medical provider, resulting in longer TTC. Older students have been reported to minimize symptoms as well (Citation35). Future work should address in-school monitoring of concussion symptoms for timely titration of accommodations and return-to-activity. Regardless, our data show that it is common for students to be in school while recovering from concussion, and that sex may be an important factor during recovery for younger students.
Concussion management and return to school
We found no difference in the number of school absences between age groups, even though the HS group had a longer TTC. Both E/MS and HS students were returning to school promptly while recovering. However, across ages, those who experienced ScRC had fewer absences than students with NScRC. CDC guidance recommending that students return to a modified school day within 2–3 days of injury was not published until 2018 (Citation10), although care models for sports concussion had moved away from strict cognitive/physical activity restrictions in 2016 (Citation25). Students’ care following concussion aligned with this most recent guidance, and for the most part, they returned to partial or modified school on expected timelines.
The majority of E/MS and HS students received recommendations for some accommodations. In line with current guidelines to return to moderate levels of activity during recovery (Citation10,Citation36,Citation37), overall modifications on physical/cognitive activity were the most common regardless of age or sex. Reducing workload as a general strategy does appear to be beneficial for students with concussions, although some students may benefit from more targeted approaches that take into account-specific symptom profiles (Citation38,Citation39). Our findings are also consistent with past research indicating that accommodations provided to students with concussion do not vary by age (Citation17). Future research should examine whether students across grade levels might benefit from accommodations that account for variable post-concussive symptoms (Citation12,Citation40). Limitations to the current study design make it unclear if students were using accommodations the whole time, if teachers implemented accommodations tailored to student needs and class demands, or if accommodations were effective in meeting academic and physical needs of students. Consistent with prior reports (Citation26,Citation27), we found that formal support mechanisms in place at schools through IEPs and 504 plans were rarely used for students with concussion. Schools should continue to rely on systems developed specifically for students with concussion, which can react quickly and flexibly to student needs (Citation26,Citation41).
We did not find differences in TTC between children with ScRC versus NScRC, but children injured in MVCs showed TTC nearly twice that of students who sustained ScRC during sports. Children who sustained NScRC in non-sport activities may also be somewhat similar to the MVC group because these injuries include mechanisms such as assaults and high-velocity injuries (like falls from significant height). In contrast to sports-related concussions, which typically include single or multiple low-velocity blunt head traumas (Citation42), high-velocity injuries are more likely to result in loss of consciousness, may produce other comorbid injuries (e.g., whiplash and orthopedic injuries), and may include a stress or anxiety response from the nature of the accident (Citation43–45). Students injured in MVCs were evaluated by physicians on approximately the same timeline as those injured in school sports, which may reflect more urgency, as opposed to students who sustained non-sports NScRC who had TTE almost twice that of their peers sustaining sports ScRC. Children injured from MVC or other high-velocity injuries may be expected to need more support for a greater period of time following concussion (Citation42,Citation46), even when provided with timely medical care. Such children with non-sports injuries may benefit from an alternative (and potentially more aggressive) return-to-learn approach compared to those with sports ScRC.
Limitations
In regard to limitations, our study did not address monitoring of students and student outcomes over time, relying on data from medical providers’ notes rather than prospectively. Another limitation is that we obtained academic accommodations from clinical notes instead of educators. Academic monitoring, including accommodations matched to student needs, would give a clearer view of the educational management of students’ needs as learners rather than as athletes or patients. Specific weekly academic monitoring of students might allow for accommodations to be titrated as needed or discontinued sooner, individualized to student needs, and for students to be referred for additional medical or rehabilitation services should symptoms persist (Citation47,Citation48). There is also the possibility that a physician could clear a student from concussion care, even as academic difficulties might persist in a way not captured by this dataset.
Perhaps most importantly, our study includes only participants who received medical care and reported their concussion to the school nurse, therefore representing a subset of students with concussion. With 17 E/MS schools and 4 high schools in this district, the mean number of concussions per year and per school from our data (E/MS = 2.26, HS = 14.4) almost certainly indicates an underrepresentation of all students injured during that time period in the district. Our data is able to characterize students who reported their concussion to the school nurse, but also is unable to describe factors related to students who did not receive care and/or did not report a concussion to the school nurse. Variability in physician recommendations for accommodations may be one factor in understanding which students report concussions to schools. Findings from one large healthcare system found accommodation recommendations to be rare upon discharge from the emergency department, and that only about half of primary care providers recommended accommodations (Citation12). Because the majority of students in our study received recommendations for some accommodations (E/MS = 94.2%; HS = 90.4%), it may be that students who were not identified or did not report to the school nurse are also those that did not receive recommendations about return to school from their medical provider. Although we are unable to test this given our school-based design, such recommendations for accommodations may be an important trigger for follow-up with school systems for management of concussion and could be useful for future investigations. Data collection also did not capture potentially informative factors that may be important in understanding injury identification and reporting (Citation8), like race, ethnicity, and socioeconomic status and thus were not available for analysis. Overall, characterizing NScRC, for which students do not receive medical care or are not reported to school, remains challenging (Citation11), underscoring the continued need to examine ways to prevent, identify, and support youth who experience concussions outside of school and in non-sports related activities (Citation8,Citation12).
Conclusion
Examining four years of data from a single school district revealed important differences about concussion identification and management across age groups. Although females, HS students, and those with NScRC may need aggressive management to avoid prolonged recoveries, E/MS students appear at risk for longer TTE, highlighting the importance of a fluid handoff from medical to educational entities to support recovery of students with concussion. Encouragingly, high schoolers are being assessed promptly, and we found no differences in management or clearance factors by sex. Recent legislation has focused primarily on management of concussion in HS athletes, with less focus on the needs of non-high school athletes and younger students. More aggressive policies to identify and manage concussion in younger students, who experience fewer ScRC, may improve care for this group of learners. Researchers, clinicians, educators, and administrators should direct particular attention to younger students with concussion who appear to be at higher risk for gaps in medical and academic support.
Acknowledgments
The authors would like to thank the Coordinators of School Health Service, Grace Vetter, RN, and JoAnn Malinowski, BSN RN NCSN, as well as all the Norwalk Public School Nurses for their work over five years on this project.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Additional information
Funding
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