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After a child sustains a concussion, he or she should be removed from the game or practice in order to allow the brain to rest. While the importance of rest following a concussion has been scientifically validated, the definition of "rest" has not been well-established. As such, an individualized approach to concussion management is preferred. While limiting physical activity is often the first area considered when a child is instructed to rest, limiting stress in other areas of life can be equally important. In addition to physical rest, cognitive and emotional rest is also important following a concussion.

Although an extreme approach to cognitive rest is sometimes recommended, studies suggest that a more moderate approach results in better long-term outcomes. In fact, scientific evidence documenting the benefits of cognitive rest is limited. Nevertheless, limiting cognitive exertion can decrease the frequency or intensity of other symptoms, such as headache.

School is the most cognitively demanding activity for most student athletes, and their baseline level of academic functioning should be considered when creating a treatment plan. Students with more severe symptoms may benefit from staying home from school for 1 to 2 days.

However, because symptoms typically resolve within a few days, formal homebound education services are generally unnecessary because the amount of instruction provided is minimal (e.g., typically only about 4 hours per week). Furthermore, homebound school services are typically reserved for students expected to miss school for an entire month.

Immediately returning to school may be a better option for some students with mild symptoms as well as students who are likely to become severely distressed if they miss a day of school. In addition, when children are told to maintain complete cognitive rest (e.g., sit quietly in a dark room with no electronics), they may become overly focused on their symptoms and consequences of rest (e.g., having to make up multiple school assignments later).

It is also important to understand the role of electronics and technology in the lives of children, especially adolescents. While using a computer or texting on a telephone may trigger headaches, completely prohibiting a teenager from engaging in these activities can result in social isolation and contribute to emotional distress. Depending upon the assignment, prohibiting all use of electronics can result in a student being unable to complete homework requiring use of a computer.

When compared to other areas, less attention is typically given to importance of emotional rest. Particularly for teenagers, social and emotional situations can be a big concern. Limiting a child's exposure to volatile emotional situations (e.g., pressure from friends and coaches to return to play, arguments between parents) is important. In addition, peers and teachers often have a variety of reactions to a child's concussion.

For example, while most people will likely respond with understanding and support. Others, however, may discount the significance of the child’s symptoms and doubt whether the symptoms are "real" because the child does not look "sick."

When the validity of symptoms is questioned, a child will sometimes unconsciously exhibit persisting or worsening difficulties. An athlete may also feel pressure from peers, teachers, or parents to return to play before they are ready, which can lead to emotional distress as well as the appearance of persisting or worsening of cognitive symptoms.

A concussion often results in increased fatigue, particularly in the first few hours after the injury. Indeed, some scientific evidence shows that physical rest during the first 24 to 48 hours may result in an overall faster recovery. In addition, because other studies have demonstrated that a concussion sustained within a week of a prior concussion can result a longer duration of symptoms, avoiding high-risk activities (e.g., returning to play) in the days following a concussion may be best.

However, studies have also shown that extreme physical rest for more than 3 days can worsen symptoms and lead to deconditioning. Most children and adolescents who sustain a concussion will stop experiencing severe symptoms within hours to days and will completely recover within a few days to a couple of weeks.

Regardless of when a student returns to school, it is important that the school nurse and all teachers be informed that the student has sustained a concussion. Following a concussion, students may exhibit inattention, distractibility, slow thinking, and confusion as well headaches, vision difficulties, and fatigue.

Some temporary accommodations can include preferential seating in the classroom (e.g., at the front of the room and away from distractions), testing in a separate room, extra time to complete tests and assignments, shortened assignments, copies of teacher notes prior to lectures, note-taking services, rest breaks during the school day, and permission to eat lunch in a quiet environment.

Considering the typically rapid recovery following a concussion, a formal accommodations plan at school is usually unnecessary because, by the time a plan has been finalized, the student is no longer symptomatic.

If, however, a child is slower to recover, a more thorough medical evaluation may be necessary to further investigate and treat physical dysfunction (e.g., headaches, dizziness). In addition, a neuropsychological evaluation can be helpful in evaluating the specific areas of cognitive difficulty and severity of the deficits as well as provide guidance regarding the need for a more formal academic plan.

About the author

Carla Hearl Morton, Ph.D., is a pediatric neuropsychologist at Cook Children's. She is a licensed psychologist with expertise in how learning and behavior are connected to the development of a child's brain structures and systems. At Cook Children's, neuropsychologists work closely with a team of neurologists andneurosurgeons to provide the best treatments and interventions that meet the individual needs of each child.

Six years ago, my life changed forever...

At that time, I was completing my postdoctoral fellowship in pediatric neuropsychology. I also became pregnant with my first child. Because I had some "inside" information about a few hospitals in the area after having worked in them, although a little farther from my home, I chose to deliver at a hospital with a competent staff and top-notch facilities -- a decision that likely saved my son's life and possibly my own. While in labor, I suddenly went into distress, and my son was quickly delivered via cesarean section. He was whisked away to the NICU before I was even able to see him.

Those of us in pediatric neuropsychology know the hundreds of things that can go "wrong" with a child even before they are born, and the downside of that knowledge is that it can give us very specific things to worry about. However, like everyone else who has experienced a similar situation, I did not really think it would happen to me. But it did. 

My son had a stroke during birth, he needed a ventilator to breathe, and he developed seizures. Unlike parents who question the role that their healthcare providers may have played in their child's condition, understanding that my son's stroke could not have reasonably been predicted brings me peace. I also know that I did not do anything to cause my son's stroke. This is different than the mothers of some of my patients who question every insignificant thing they did or did not do during their pregnancy because it might have played some tiny role in their child's condition.

Although most parents remember their baby's weight and length, the more important information for me was his Apgar scores and the location and extent of brain damage I saw on his imaging. Unlike most people in my situation, I did not have to ask about the potential future outcomes. I had worked with children who had severe disabilities, and I knew it was possible that my son could emerge with significant challenges. However, I was probably less frustrated whenever I was told that his future level of functioning was uncertain.

Having been on the other side of that conversation, I knew it is often difficult to predict what will happen several years in the future, particularly while a child is very young. Although some doctors like to be optimistic about a child's prognosis, others prefer to provide a more pessimistic assessment so that the parents may be pleasantly surprised by their child's better-than-expected outcome. I agree that most people prefer a definitive answer, even if it is one that they dislike, but "I don't know" is often the most honest answer to a parent's question.  

Related Links:

• Cook Children's Stroke and Thrombosis Program
• A stroke at birth - part 1
• Stroke at birth - part 2
• Stroke at birth - part 3
• Stroke at birth - part 4

About the author

Carla Hearl Morton, Ph.D., is a pediatric neuropsychologist at Cook Children's. She is a licensed psychologist with expertise in how learning and behavior are connected to the development of a child's brain structures and systems. At Cook Children's, neuropsychologists work closely with a team of neurologists and neurosurgeons to provide the best treatments and interventions that meet the individual needs of each child.