Concussions: Treatment and Impact to Learning

Transcription

1 Concussions: Treatment and Impact to Learning School Nurse Update August 19 and 20, 2015 Andrea Dorsch, Ph.D. Pediatric Neuropsychology Pediatric Psychology and Psychiatry Services

2 Oh, you just got your bell rung. Get back in there and play! Oh, how far we have come!! Removal from play following concussion Increased awareness of post-concussive symptoms Recognition of need for cognitive and physical rest Recognition of need for accommodations in school

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4 Concussion Symptoms Potential Implications in School Physical symptoms Headache Sensitivity to light Sensitivity to noise Negative effect on attention and learning Difficulties reading and copying from board Sensitivity to fluorescent lighting, reduced tolerance for screen time Difficulties in noisy environments (cafeteria, band, shop, assemblies, halls) Cognitive symptoms Concentration difficulties Memory difficulties Slow processing speed Mental fogginess Difficulties with Following and recalling directions Comprehending and learning new concepts and tasks Retrieving previously learned material Test-taking Emotional Symptoms Irritability / Moodiness Emotional meltdowns Fatigue/ Sleep issues Disrupted/insufficient sleep Mental fatigue Negative effect on attention and memory Sleeping in class Tardiness or absences

5 Concussion Symptoms Accommodations in School Physical symptoms Headache Sensitivity to light Sensitivity to noise Rest breaks during day Allow rest period in nurse s office Early dismissal from class to avoid busy hallways No PE, no activities in gym or on playground Avoid band, shop, computer classes if symptoms provoked Excuse from activities in noisy environments (e.g., assemblies, cafeteria) Provide pre-printed notes, written directions Cognitive symptoms Concentration difficulties Memory difficulties Slow processing speed Mental fogginess Excuse non-essential work, student to complete representative work No double workload of make-up work and new work Additional time for assignments/ tests, flexible due dates Use aides (e.g., calculators, computers) Assign peer note-taker, provide teacher notes Emotional Symptoms Irritability / Moodiness Fatigue/ Sleep issues Disrupted/insufficient sleep Mental fatigue Allow student to remove self/ use signal (e.g., yellow card) to leave class Encourage visit with supportive adult (e.g., school nurse, advisor, coach) Late arrival or early dismissal Rest breaks during day Offer study period/study skills class Alternate tasks

6 Return-to-Learn Plan Stage Activity Objective No activity Gradual reintroduction of cognitive activity Complete cognitive rest - no school, no homework, no reading, no texting, no video games, no computer work. Relax previous restrictions on activities and add back for short periods of time (5-15 minutes at a time). Recovery Gradual controlled increase in subsymptom threshold cognitive activities. Homework at home before school work at school Homework in longer increments (20-30 minutes at a time). Increase cognitive stamina by repetition of short periods of self-paced cognitive activity. School re-entry Part day of school after tolerating 1-2 cumulative hours of homework at home. Gradual reintegration into school Increase to full day of school. Re-entry into school with accommodations to permit controlled subsymptom threshold increase in cognitive load. Accommodations decrease as cognitive stamina improves. Resumption of full cognitive workload Introduce testing, catch up with essential work. Full return to school; may commence Return-to-Play Source: Master CL, Gioia GA, Leddy JJ, Grady MF. Pediatric Annals, 2012.

7 Example of a Symptom Monitoring Tool Source: Master CL, Gioia GA, Leddy JJ, Grady MF. Pediatric Annals, 2012

8 Risk Factors for Prolonged Recovery Previous concussion Cumulative effect of repeated concussions Increased vulnerability Pre-existing or undiagnosed conditions Personal or family history of headache Neurodevelopmental disorders (e.g., ADHD, LD, ID, ASD) Psychological issues (e.g., anxiety, depression)

9 Environmental Risk Factors for Prolonged Recovery Tendency toward somatization Unrealistic expectations for recovery Poor symptom management Poor adherence to rest in acute period Performance pressure Trauma history Family stressors

10 Less Obvious Risk Factors for Prolonged Recovery High achievement Limited experience with adversity Over-coping/ over-controlled personality

11 Current School Environment: A Risk Factor for Academic Failure? Increasing grade level standards Increasing requirements for graduation Emphasis on rote learning High-stakes testing

12 Absence from School : A Risk Factor for Academic Failure? Are accommodations needed because of concussion symptoms or because of school absence?

13 Controversy over Cognitive Rest When Is Rest Doing More Harm Than Good? Look how far we have come Or have we gone too far? Is physical and cognitive rest too restrictive? Is too much rest creating academic and emotional problems? Are symptoms & symptom reporting reinforced by emphasis on rest?

14 Controversy over Cognitive Rest When Is Rest Doing More Harm Than Good? Social isolation Disruption of sleep cycle Loss of achievement Loss of stress-relieving activities Increased risk of anxiety/ depression Increased symptom focus/ symptom reporting Learned helplessness Avoidance of challenges

15 Symptom Overlap or Co-occurrence? Anxiety Depression Sleep difficulties Headache

16 Generalized Anxiety Disorder 1. Restlessness or feeling keyed up or on edge 2. Being easily fatigued 3. Difficulty concentrating or mind going blank 4. Irritability 5. Muscle tension 6. Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

17 Major Depressive Disorder 1. Depressed mood or irritable most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). 2. Decreased interest or pleasure in most activities, most of each day 3. Significant weight change (5%) or change in appetite 4. Change in sleep: Insomnia or hypersomnia 5. Change in activity: Psychomotor agitation or retardation 6. Fatigue or loss of energy 7. Guilt/worthlessness: Feelings of worthlessness or excessive or inappropriate guilt 8. Concentration: diminished ability to think or concentrate, or more indecisiveness 9. Suicidality: Thoughts of death or suicide, or has suicide plan

18 Persistent Depressive Disorder (Dysthymia) 1. Poor appetite or overeating 2. Insomnia or hypersomnia 3. Low energy or fatigue 4. Low self-esteem 5. Poor concentration or difficulty making decisions 6. Feelings of hopelessness

19 Avoid additional impact/ repeat injury during recovery Achieving Balance Balance risk and benefit of participation in school & sports If prolonged course & limited response to intervention, RTL w/o complete symptom resolution Reduce risk of academic failure through adjustments in school

20 Why I Love School Nurses School nurses recognize relationship between PCS and stress Using a concussed brain to learn may increase symptoms and prolong recovery Cognitive rest for a short time may reduce symptoms and speed recovery Adjusting expectations is as or more important than rest

21 Why I Love School Nurses School nurses recognize relationship between PCS and stress RTL plan must be individualized based on academic demands and student resources Forgiveness of missed work, representative work, focus on mastery, and accommodations are essential to reduce risk of academic failure Pre-existing conditions and stressors may prolong symptoms and need to be addressed

22 Pediatric Concussion Resources Brain Injury Alliance of Washington (BIAWA) Pediatric Resources BIAWA Pediatric Resource Management Centers for Disease Control and Prevention (CDC): HEADS UP REAP TM : Remove/Reduce, Educate, Adjust/Accommodate, Pace Suggested School Adjustments Concussion Management Guidelines

23 Contact Information Andrea Dorsch, Ph.D. Pediatric Neuropsychology Pediatric Psychology and Psychiatry Services Mary Bridge Children's Clinics/ MultiCare Health System