Important Factors to Consider When Returning Concussed Youth to School

| By Rebecca Babcock

Study Shows Returning to School is a Unique Consideration for Concussed Youth

In comparison to adults, youth who suffer a sport-related concussion have to manage different factors, such as returning to school (RTS). Therefore, a 2018 study systematically reviewed academic literature concerning concussions in youth and RTS (1). Specifically, the study examined two questions: 1) what factors must be considered in RTS following concussion, and 2) what strategies or accommodations should be recommended following concussion?

Student athletes who continued to play after injury took twice as long to recover and were 9x more likely to have prolonged recovery

Factors To Consider

This study identified elements that tend to negatively impact a student’s ability to RTS. The list below summarizes these factors.

  1. Number of Symptoms or Symptom Severity: a higher number of symptoms or greater symptom severity indicated there was a greater chance of youth missing more days of school and having challenges RTS (2-6).
  2. Types of Symptoms: specific symptoms, such as: headache, fatigue, visual disturbances, memory deficits, difficulty concentrating, executive dysfunction, and vestibular abnormalities, negatively impacted a student’s ability to RTS (2-4,6-8).
  3. Duration of Symptoms: symptoms that lasted longer meant the students had more difficulty with RTS (2,5)
  4. Age/Grade: adolescents/high school students tended to suffer from: a) more symptoms, and b) more severe symptoms which was associated with taking longer to, and having more difficulty in, RTS in comparison to younger children (3-6,9-10). In one study, youth aged 13 years and older was a predictor of persistent symptoms (11). These trends may reflect increased academic and social demands, greater challenges to coordinate management strategies across multiple classes, and “greater independence and decreased supervision in compliance with medical recommendations” (1).
  5. Courses: math caused the most problems for students RTS followed by reading/language, arts, science, and social studies classes (5).
  6. Rest: youth who did not immediately rest after injury took longer to RTS (12). In fact, increased school attendance and higher cognitive loads after injury were associated with persistent or exacerbated symptoms (12-15). Student athletes who continued to play after injury took twice as long to recover and were 9x more likely to have prolonged recovery (16).
  7. Socioeconomic Status: youth with private insurance missed more days of school after a concussion than youth with public insurance (17).

What Accommodations Can Be Made?

Three interesting trends were found that could be helpful in developing specific accommodations other than increased school absence. First, most students were able to RTS after 2-5 days (14,18-19). Second, 45% of students may experience exacerbation or recurrence of symptoms when RTS (9). Third, anywhere from 17-73% of students received accommodations and/or experienced difficulty at school (2-4,7,10,18,20). Most interestingly, schools that had concussion policies were more likely to provide concussed students with accommodations in comparison to schools who did not have a policy (21). Similarly, students who had a medical RTS letter or received outpatient medical follow-ups were also more likely to be provided with accommodations (10,18).

More Research Needed

Due to the study’s reasonable inclusion criteria, only 17 studies were assessed for this systematic review. Ultimately, more research is needed in order to establish RTS processes and accommodations that are guided by clinical evidence.


  1. Purcell LK, Davis GA, Gioia GAWhat factors must be considered in ‘return to school’ following concussion and what strategies or accommodations should be followed? A systematic reviewBritish Journal of Sports Medicine 2019;53:
  2. Baker JG , Leddy JJ , Darling SR , et al. Factors associated with problems for adolescents returning to the classroom after sport-related concussion. Clin Pediatr 2015;54:961–8.
  3. Corwin DJ, Wiebe DJ, Zonfrillo MR, et al. Vestibular deficits following youth concussion. J Pediatr 2015;166:1221–5
  4. Purcell L, Harvey J, Seabrook JA. Patterns of recovery following sport-related concussion in children and adolescents. Clin Pediatr 2016;55:452–8.
  5. Ransom DM, Vaughan CG, Pratson L, et al. Academic effects of concussion in children and adolescents. Pediatrics 2015;135:1043–50.
  6. Ransom DM, Burns AR, Youngstrom EA, et al. Applying an evidence-based assessment model to identify students at risk for perceived academic problems following concussion. J Int Neuropsychol Soc 2016;22:1038–49
  7. Darling SR, Leddy JJ, Baker JG, et al. Evaluation of the Zurich Guidelines and exercise testing for return to play in adolescents following concussion. Clin J Sport Med 2014;24:128–33.
  8. Lovell MR, Collins MW, Iverson GL, et al. Recovery from mild concussion in high school athletes. J Neurosurg 2003;98:296–301.
  9. Carson JD, Lawrence DW, Kraft SA, et al. Premature return to play and return to learn after a sport-related concussion: physician’s chart review. Can Fam Physician 2014;60:e310–e12-5
  10. Zuckerbraun NS, Atabaki S, Collins MW, et al. Use of modified acute concussion evaluation tools in the emergency department. Pediatrics 2014;133:635–42
  11. Zemek R, Barrowman N, Freedman SB, et al. Clinical risk score for persistent postconcussion symptoms among children with acute concussion in the ED. JAMA 2016;315:1014–25
  12. Taubman B, Rosen F, McHugh J, et al. The timing of cognitive and physical rest and recovery in concussion. J Child Neurol 2016;31:1555–60.
  13. Brown NJ, Mannix RC, O’Brien MJ, et al. Effect of cognitive activity level on duration of post-concussion symptoms. Pediatrics 2014;133:e299–304.
  14. Makki AY, Leddy J, Hinds A, et al. School attendance and symptoms in adolescents after sport-related concussion. Glob Pediatr Health 2016;3:1–3.
  15. Silverberg ND, Iverson GL, McCrea M, et al. Activity-related symptom exacerbations after pediatric concussion. JAMA Pediatr 2016;170:946–53
  16. Elbin RJ, Sufrinko A, Schatz P, et al. Removal from play after concussion and recovery time. Pediatrics 2016;138:e20160910.
  17. Zuckerman SL, Zalneraitis BH, Totten DJ, et al. Socioeconomic status and outcomes after sport-related concussion: a preliminary investigation. J Neurosurg Pediatr 2017;19:652–61.
  18. Grubenhoff JA, Deakyne SJ, Comstock RD, et al. Outpatient follow-up and return to school after emergency department evaluation among children with persistent postconcussion symptoms. Brain Inj 2015;29:1186–91.
  19. Thomas DG, Apps JN, Hoffmann RG, et al. Benefits of strict rest after acute concussion: a randomized controlled trial. Pediatrics 2015;135:213–23.
  20. Corwin DJ, Zonfrillo MR, Master CL, et al. Characteristics of prolonged concussion recovery in a pediatric subspecialty referral population. J Pediatr 2014;165:1207–15.
  21. Glang AE, Koester MC, Chesnutt JC, et al. The effectiveness of a web-based resource in improving postconcussion management in high schools. J Adolesc Health 2015;56:91–7.