UNDERSTANDING THE COGNITIVE AND PSYCHOLOGICAL SEQUELAE OF A CONCUSSION IS CRITICAL FOR MANAGINIG RECOVERY FROM MILD TRAUMATIC BRIAN INJURY.  Educating parents and teachers on the impact of a concussion on academic performance can help reduce recovery complications of prolonged symptoms and psychological distress.

Though cognitive and psychological changes following a concussion vary in intensity and duration, they are most often temporary, lasting a few days to weeks. Cognitive changes after a concussion may include: slow processing of information, poor sustained attention and concentration, difficulty remembering new information, trouble planning and organizing materials, difficulties with visual-spatial information, slow reaction time, poor impulse control and feeling cognitively "foggy." Psychological changes may include: emotional sensitivity and fluctuation, irritability and anxiety. Variability in symptoms depends on the severity of the injury and the athlete's cognitive, psychological and medical history. Athlete's with a history of previous concussions or neurological disorders tend to take longer to recover and their cognitive symptoms can be more severe. Cognitive weaknesses associated with a history of a learning disability or ADHD tend to be exacerbated following a mild head injury, as do mood and anxiety symptoms in children and teens with a history of these symptoms. In teens, the psychological symptoms can be difficult to tease apart, given that this is a time when it is developmentally normal tobe emotionally sensitive or irritable.

Just as returning to aerobic exercise too soon will prolong the recovery of a concussion, returning to mental exercise too soon will interfere with recovery and may lead to more serious outcomes. Allowing your child to sleep and rest, along with reducing environmental stimulation as much as possible will help with his/her recovery. This includes initially eliminating electronic use (video games, texting, computer, tv), reducing noise and light stimulation, limiting socializing and avoiding homework until their physical symptoms of concussion (headache, dizziness, blurred vision, sensitivity to noise or light, fatigue or nausea) have improved. As a general rule, a child should not return to school unless they can sustain their attention for approximately 45 minutes without demonstrating any of the physical symptoms of concussion. To assess if your child is ready for school work, give them a task, such as reading, for 10 minutes and see if they have any physical symptoms afterwards. If yes, back off and have them rest. If not, increase it to 20 minutes and assess symptoms. Continue to increase by 10 minutes, backing off when they reach a point of developing a headache, dizziness or other physical symptom. Try this for reading, math, computer assignments etc.. When ready, they should return to school following a gradual process. This may mean that they attend partial days or take frequent breaks during the day to rest at the nurse’s office, away from light or noises.
 

What to look for

In terms of what the cognitive changes from a concussion "look like" at home or school, it usually means: trouble following directions, paying attention, taking notes and not enough time to read, write or finish an assignment or test during class. Subjects such as math, science and foreign language tend to be more difficult following a concussion because these are considered more "emerging" and less well encoded/rehearsed materials that the child is learning. It's always helpful to re-introduce the material a child was learning PRIOR to his/her concussion, before advancing to new material. Once they have mastered the prior material, they can proceed to new material. In the classroom, they may need accommodations such as: seating in the front of the room, access to teacher's notes/outlines/study guides, individual teaching sessions, extended time for tests or projects, help with prioritizing their work, reduction in homework and excused from or modification in exams. It's important for teachers to recognize that even if a child is able to attend school, they may not have the energy to complete the homework or study for an exam. Therefore, parents and teachers/guidance counselors need to be in daily communication. If a child feels stressed about his/her school work, it not only increases their risk for psychological sequelae, but also prolongs the recovery from concussion. For children attending public school, the parent or school may determine it is necessary to implement a temporary 504 Plan, which legally documents a child's needs for accommodations in the classroom.
 

In Summary

Following a concussion, reducing cognitive stimulation and mental exercise is equally as important as reducing aerobic/sporting activities. Parents should contact their child's school to develop a plan and seek professional help from a qualified neuropsychologist if you have concerns about your child's psychological symptoms or school performance, if your child has a history of multiple concussions or neurological disorder or child's symptoms are prolonged for several weeks.

Dr. Ryan is availale for concussion related workshops and for consultation on development of concussion management programs for sports teams or schools. She can be reached at her clinical office in Darien, CT at 203-636-0080. ext 584 or via email Tmcdonoughryan@gmail.com.