Physician recommended school accommodations and student outcomes following a mild traumatic brain injury among youth with persistent post-concussive symptoms

1Background

Each year, an estimated 1.1 million to 1.9 mil-lion sports- and recreation-related concussions (SRC) occur among children in the United States (US) (Bryan, Rowhani-Rahbar, Comstock, & Rivara, 2016). Mild traumatic brain injury, including concussions, are associated with emotional, physical, and cognitive symptoms (McCrory et al., 2017). Although concussion symptoms typically resolve within two to four weeks after injury, some youth experience persistent post-concussive symptoms (PPCS) for months (Graham, Rivara, Ford, & Spicer, 2014).

Best practices in concussion focus on symptom identification and management with the goal of facilitating a safe resumption of activities, including return-to-learn (RTL) or return-to-school (Lumba-Brown et al., 2018; McCrory et al., 2017). However, RTL may be negatively affected by post-concussive symptoms (Neelakantan et al., 2020), and students with more numerous or severe symptoms, including those with persistent symptoms, may experience symptom exacerbation with RTL (Silverberg et al., 2016). Current guidelines also suggest minimizing absence from school, as prolonged rest lengthens recovery time (Thomas, Apps, Hoffmann, McCrea, & Hammeke, 2015). The importance of finding a balance for students between rest and activity is reflected in the 2018 Center for Disease Control and Prevention Guideline, which provides a strategy for assisting students in a gradual return to full school activities while monitoring symptoms and implementing appropriate school accommodations (Lumba-Brown et al., 2018).

Healthcare providers can play an important role in guiding students back to RTL and advising on needed accommodations following concussion. School accommodations may include attendance modifications (no school, half-day), providing breaks as needed, decreasing student workload (reducing homework, extra assistance), addressing visual and auditory stimuli (allowing sunglasses/earplugs, additional time for transition between classes), or implementing a 504 Plan (Halstead et al., 2013; Howland, Hackman, Torres, Campbell, & Olshaker, 2021). A 504 plan is a formal process carried out by publicly funded schools, as part of a United States Rehabilitation Act of 1973, to provide appropriate aids and services designed to meet the needs of students with disabilities (Halstead et al., 2013). Factors considered for recommendations may include symptoms, age, history of concussion, and prior learning difficulties (Lumba-Brown et al., 2018). With a wide variation in state-level RTL legislation and school-level compliance to national RTL recommendations (Olympia, Ritter, Brady, & Bramley, 2016; Thompson et al., 2016), physician recommendations may offer an opportunity to intervene with appropriate RTL protocols.

Students with concussion are at risk for unfavorable short (< 3 months) and long (≥12 months) term academic performance outcomes (Neelakantan et al., 2020), and cognitive demand with RTL may worsen symptoms (Silverberg et al., 2016). Students may also experience psychological impairments such as depression and anxiety immediately or after RTL (Yrondi, Brauge, LeMen, Arbus, & Pariente, 2017). However, a 2019 study found that students with concussion who returned to school find reduced attendance requirements, excused non-participation in physical education classes, and open communication with teachers to be very helpful in their RTL (Russell, Selci, Black, Cochrane, & Ellis, 2019). Hence, short- and long-term academic, symptomatic, and psychological outcomes following school accommodations are interests of study. Appropriate accommodations supporting students may modify the extent of impairments. However, studies supporting the ideal management of RTL are limited (Lumba-Brown et al., 2018), and the effectiveness of school accommodations on concussive symptoms and student outcomes, particularly among youth experiencing PPCS, is understudied (DeMatteo, Bednar, Randall, & Falla, 2020). The purpose of this study was to examine physician recommendations for academic accommodations and associations with short- and long-term student outcomes among youth experiencing PPCS.

2Methods

3Results

Of the 200 adolescents, 62.0% were female and 82.0% were White (Table 2). The mean age was 14.7 years (SD = 1.7) and approximately two-thirds were high school students. Sixty eight percent of the adolescents had parents who completed a bachelor’s degree or higher and 84% carried private medical insurance.

Days from injury to study entry was significantly and negatively associated with the number of recommended accommodation categories (0–3 versus≥4 categories) within 90 days after the injury (p < 0.001). Most evaluations were conducted by Sports Medicine clinicians (84%). Analysis across medical specialties was not conducted due to overlap of specialties that the adolescents consulted. No other significant differences by number of accommodation categories were detected.

Among the adolescents experiencing PPCS, 14% (n = 28) did not receive recommendations for school accommodations by a physician within 90 days post-injury: either by not visiting a clinic within the first 90 days of injury or not receiving recommendations at clinic visits. However, among those who were recommended for school accommodations, a majority (70%) received recommendations across four or more categories of accommodations (Table 3). The mean number of recommended accommodation categories was 3.7 (SD = 1.8) at the first visit, and generally decreased as the number of visits increased (Table 3). The number of adolescents visiting the clinic also decreased with increasing visits. Among the school accommodation recommendations made at the first visit, the most frequent were non-specific (83.8%; physician recommended “non-specific” and/or “meet with school counselor”) and the least frequent were 504 plans (10.3%). However, the proportion of participants with recommendations for 504 plans increased for those who continued to have clinic visits.

Table 4 presents the associations between recommended school accommodations within 90 days post-injury and student outcomes at three months after study entry, adjusted for school grade, group assignment, prior learning disability/ADHD, prior utilization of special education services, days from injury to study entry, and baseline HBI scores. More school accommodation recommendations were associated with increased count of school problems as reported on the CLASS questionnaire at three months after study entry (aRR 1.18, 95% CI: 1.12–1.24). Adolescents who received≥4 recommendations also experienced more school problems compared to those who received 0–3 recommendations for school accommodations at three months after study entry (aRR 1.98, 95% CI: 1.59–2.47). Recommendations for all six categories of accommodations were positively associated with the number of problems at school reported at the three month time point. No significant associations were found between the recommended school accommodations and student evaluations of concussion-related symptoms, depression, anxiety, and HRQOL at three months post study entry.

Table 5 presents the adjusted associations between recommended school accommodations within 90 days post-concussion and student outcomes at 12 months after study entry. The number of recommended accommodations was positively associated with the count of reported problems at school (aRR 1.11, 95% CI: 1.05–1.18). Adolescents who received≥4 recommendations for accommodations also reported more problems at school at 12 months post study entry compared to those who received 0–3 recommendations (aRR 1.40, 95% CI: 1.08–1.80). Recommendation categories were significantly associated with the number of reported problems at school for “Expanded academic adjustments” (aRR 1.79, 95% CI: 1.34–2.38), “Academic accommodation” (aRR 1.72, 95% CI: 1.29–2.30), and “Academic schedule modifications” (aRR 1.57, 95% CI: 1.21–2.02). Receiving recommendations across≥4 (vs. 0–3) accommodation categories was positively associated with HBI scores reported at 12 months post study entry (adj coeff 3.43, 95% CI: 0.08–6.78). No significant associations were detected between recommended school accommodations and student evaluations of depression, anxiety, and HRQOL.

Recommended accommodations within 90 days of concussion were not significantly associated with student GPA at six or 12 months post-concussion (adj coeff = –0.04, 95% CI: –0.09–0.01; adj coeff = –0.03, 95% CI: –0.08–0.02).

4Discussion

This study demonstrated a positive association between the number of physician recommended school accommodations and the number of reported school problems at three and 12 months after study entry among adolescents with PPCS. During the first 90 days after concussion, the number of adolescents with repeat visits decreased and adolescents received progressively fewer school accommodation recommendations, but the proportion of recommendations for formal 504 plans increased for students who continued to have clinic visits. There was no relationship between recommendations for school accommodations made by physicians and GPA, concussion symptoms, depression, anxiety, and HRQOL outcomes. Collectively, these findings support a role for physicians in supporting RTL efforts and suggest the need for future work examining how physician recommendations are implemented in schools.

Research indicates that adolescents who RTL without the needed rest or RTL accommodations take longer to recover and experience exacerbated symptoms after concussion (Brown et al., 2014, Silverberg et al., 2016). Therefore, our finding that adolescents who report more problems post-concussion received more physician recommendations for RTL accommodations suggests that students who need more accommodations were recommended to receive them. Since there is large variation in concussion guidelines for RTL accommodations and few schools have formal RTL policies, teachers often rely on physician recommendations for RTL (Bevilacqua et al., 2021; Howland, Hackman, Torres, Campbell, & Olshaker, 2021). Physician assessments and recommendations are also needed for students with concussion because students may underestimate symptoms they are experiencing compared to those who receive formal examinations by physicians (Post, Snedden, Snedaker, Bouton, & Wang, 2021).

We observed no significant associations between categories of recommended accommodations and three month student outcomes including post-concussive symptoms, anxiety symptoms, depressive symptoms, and HRQOL. These results were also reflected in the 12 month outcomes. This may indicate the need to examine how physicians make RTL recommendations, and how recommended RTL accommodations are implemented at schools, both of which were beyond the scope of this study. In the absence of formal RTL school policies, stronger engagement between adolescents, parents, and physicians may be needed to support implementation of concussion related RLT accommodations.

While our sample lacked diversity, our study indicated that the number of school accommodations recommendations did not significantly differ by soc-ioeconomic factors such as parent education, insurance status, race, ethnicity, and household income. However, disparities of post-concussion outcomes across socioeconomic factors are documented in literature (see, e.g., Holmes et al., 2016). This discrepancy may be indicative of a disparity in implementation of recommended accommodations for concussion that result from disparities of resources at the school level (Kroshus, Rivara, Whitlock, Herring, & Chrisman, 2017). Although this study showed that adolescents who accessed physician care received recommendations equally across socioeconomic lines, the implementations of these recommendations may not be equitable across schools. Again, future studies on implementation of school accommodations are needed. A combination of physician involvement, better communication between schools and physicians, and strengthening school implementation of RTL recommendations, particularly at schools with less resources are likely needed to reduce concussion outcome disparities.

This study has both strengths and weaknesses. For instance, the parent study did not limit access to medical specialties for concussion care, which strengthens the study by offering generalizability across medical specialties. Further, we examined six outcomes to understand the effect of physician RTL recommendations on the whole student by including academic, symptomatic, and psychological outcomes. A limitation of the study is that the study lacked student diversity, with the sample of predominately White and high income, which reflects participants in the parent study. Further, the inclusion criterion of at least three PPCS lasting between≥1 and < 9 months after injury resulted in considerable variation in the time between injury and study entry for the sampled youth. The heterogeneity of enrollment time after the injury may have impacted the ability to detect associations of outcomes with recommendations made≤90 days post-injury. The clinic visits≤90 days post-injury may not have occurred at the same time as the three month post study entry survey measures, making the interpretation of associations difficult. An additional limitation is the lack of data on interdisciplinary rehabilitation approaches where a student with a concussion receives coordinated guidance from a variety of care providers. Finally, recommendations for accommodations made by non-physicians such as athletic trainers and school nurses were not captured in this study, limiting generalizability.

5Conclusion

Physician recommendations for academic accommodations within 90 days following concussion reflected adolescent needs. However, GPA, concussion symptoms, depression, anxiety, and HRQOL outcomes were not associated with recommended accommodations, suggesting a potential gap between physician recommendations and school implementation. Ensuring appropriate implementation of RTL recommendations through partnerships between physicians, students, and school systems may be needed to achieve student centered RTL and academic achievement following concussion.