School Nurses

Young children and concussion

Whenever a concussion is suspected, the first step is to see a physician or other qualified healthcare professional knowledgeable in the identification, treatment, and management of concussion. The Centers for Disease Control and Prevention (CDC) states that “Physicians can play a key role in helping to prevent a concussion and to improve a patient’s health outcomes through early diagnosis, management, and appropriate referral” and “Symptoms of a concussion may appear mild, but can lead to significant, life-long impairment affecting an individual’s ability to function physically, cognitively, and psychologically.” Considering that not much is known about the effects of concussion on young children, it is critical that concussion management for young children is approached with the utmost caution.

The 2008 International Conference on Concussion in Sport Consensus Statement states that young children do not lose consciousness as easily as teens and older children. In addition, they may not have the language skills necessary to describe concussion symptoms they might be experiencing. Instead they may be more likely to complain of physical symptoms or act out behaviorally in response to their symptoms, often complaining that they just “don’t feel good.” Recent preliminary research findings suggest that young children may need to take longer periods of rest following concussion. It is commonly recommended that they take at least an additional 7 day rest/recovery period after they are symptom-free.

School nurses working in elementary and middle schools may or may not have received an updated school policy or protocol to follow in the event of a suspected concussion.

School nurses are key staff members in elementary and middle schools who most likely have the most comprehensive knowledge about the current understanding of concussion and concussion issues. Concussions happen from car crashes, falls, and schoolyard accidents among many other things. The issues that arise from sports-related concussions are mostly related to decisions that need to be made about whether a student-athlete should continue practice or competition when a concussion is suspected. School districts can choose to provide guidelines for elementary and middle schools to follow in the event that a concussion occurs to a student outside of interscholastic sports.

What is in the law and model policy?

The New Jersey Concussion Law applies to all public and nonpublic schools in New Jersey and to student-athletes in grades K – 12 who play interscholastic sports. The law primarily focuses on interscholastic sports, with the exception that any youth sports team organization operating on school grounds must sign a statement of compliance with that school district or nonpublic school’s policies for the management of concussions and other head injuries. This article in the law grants the youth sports organization immunity from liability when they sign the compliance statement.

The model policy developed by the New Jersey Department of Education expands the law regarding return-to-play decisions to include grades K-12 with certain distinctions for grade levels K-8. It states that “Younger students (K-8) should observe the 7 day rest/recovery period (after they are symptom free at rest) prior to initiating the Graduated return-to-play Protocol” outlined in the Consensus Statement from the 2008 International Conference on Concussion in Sport. The policy also states that the Graduated return-to-play Protocol should be monitored by a physician trained in the evaluation and management of concussion as well as the parents/guardians of the student-athlete and that school nurses may serve as advocates for communicating signs and symptoms to physicians and parents/guardians.

The NJ concussion law requires that if a student athlete sustains, or is even suspected of having sustained a concussion while playing in a game or practice, the athlete must be immediately removed from play and should not return to sports activity for the remainder of the day. Following removal from play, the athlete must be evaluated by a healthcare provider if available at the school or an urgent referral should be arranged. Immediate removal from play is important, even if the athlete feels better on the sideline, because symptoms may often not fully manifest until hours or days after the incident.

The model policy also contains the following protocol to follow when a concussion is suspected in interscholastic sports:

  1. Immediate removal from practice or competition. 911 should be called if there is a deterioration of symptoms, loss of consciousness, or direct neck pain associated with the injury.
  2. Student-athlete should be evaluated by the school’s licensed healthcare provider who is trained in the evaluation and management of concussion.
  3. School personnel (athletic Director, building administrator, certified athletic trainer (ATC), School Nurse, Coach, etc.) next contacts parent/guardian and informs that a concussion is suspected.
  4. School provides student-athlete with district board of education approved suggestions for management/medical checklist to give to the parent/guardian, and physician or other licensed healthcare professional trained in the evaluation and management of concussion.
  5. The student-athlete must receive written clearance from a physician, trained in the evaluation and management of concussions that states the student-athlete is asymptomatic at rest and may begin the district’s graduated return-to-play protocol. Medical clearance that is inconsistent with district, charter, and non-public school policy may not be accepted and such matters will be referred to the school/team physician.

The return-to-play protocol included in the New Jersey Model Policy on Concussion was adopted from the Consensus Statement from the 2008 International Conference on Concussion in Sport and provides for a student-athlete to move through the protocol over at least a five-day process with exertion increasing each day. A clinician monitors the protocol to observe whether or not symptoms re-occur at any time during the process. If any symptoms re-occur the student-athlete must go back to the previous step before proceeding with the protocol. A key to making safe return-to-play decisions is to be certain that the student-athlete understands the importance of reporting any symptoms during the recovery process. Information from the student-athlete, school nurse, physician, athletic trainer, coach, parents/guardians, teachers, and even peers should be considered throughout recovery and included in the return-to-play decision making. Training on concussion is available from a variety of sources for each of these individuals; it is important for all individuals working with student-athletes to be well informed and knowledgeable about concussion issues.

The graduated return-to-play protocol provides a measure of protection against the risk of second-impact syndrome. The term second-impact syndrome describes an event that results in death or lifelong disability because an athlete sustains a second blow or hit before a concussion is completely resolved; the force of the hit does not seem to be significant to the onset of sudden impact syndrome. Research is ongoing to learn more about second impact syndrome as it seems to be something that only affects adolescents and young adults.

Another concussion issue often discussed among school professionals is baseline testing. It is not mandated in the New Jersey Concussion Law or the model policy. It is just one tool to assist physicians in diagnosing a concussion and making safe return-to-play decisions; however, it is the only objective tool available to clinicians who treat and manage concussions. All other decisions made regarding concussion are subjective to the knowledge of the clinicians treating the concussion and the accuracy of the information provided by individuals comprising the team that monitors recovery from concussion. Depending on the school setting the team can consist of the student-athlete, school nurse, physician, athletic trainer, coach, parents/guardians, teachers, peers/teammates, and others.

Children as young as 12 years can benefit from establishing a cognitive baseline when they participate in organized sports. Baseline testing is a brief neurocognitive computerized test that is taken in order to provide information about how an individual performs certain cognitive functions that can include attention span, working memory, sustained and selective attention time, response variability, non-verbal problem solving, and reaction time; individual programs have specific differences. There are numerous baseline testing software companies that make baseline testing available to individuals, teams and other groups.

The computerized neurocognitive test typically used for baseline testing is different from a complete neuropsychological evaluation. A typical complete neuropsychological evaluation takes about ten hours to complete and provides detailed information about the brain behavior relationships for an individual. A neuropsychological evaluation may become important when the symptoms of a concussion persist and the physician refers the patient to a neuropsychologist for further evaluation.

What is your school district’s policy on concussion?

It is important that all school staff are aware of their district’s concussion policy and how it pertains to them. Education is an important part of the New Jersey Concussion Law and Model Policy. It is mandated in the Law that school physicians, athletic trainers, and coaches take a training course on concussion in youth sports; the Model Policy expands this to include school nurses. It is also mandated that a fact sheet on concussion is provided to parents of students participating in interscholastic sports.

Concussion in community sports and recreational activities

Community-based youth sports programs are quite different from interscholastic sports with regard to structure of the organization, accountability, and training of coaches and other staff; very often the only adult in charge of the sports event is a parent volunteer. Interscholastic sports are governed by rules established by the New Jersey Interscholastic Athletic Association and are bound by a school district’s Board of Education policy regarding protocol for when an injury may have occurred during a school sports event. Therefore if a concussion is suspected during a community sports event on school property the mandates in the Law apply the same as they would if the suspected concussion occurred during an interscholastic sports event at school.

What is your role?

The school nurses’ office is often a sanctuary for students of all ages. Students are distanced from academic demands and their personal issues are attended to. They feel understood, secure, and cared for – with good reason. School nurse roles vary from clinical when administering medication to administrative when providing an excuse from gym class when something hurts. Nurses provide education to students, parents and other school professionals. They advocate for their students’ needs. They are often the only medical staff on school grounds.

There are many things a school nurse can do to facilitate education on preventing, managing, and raising awareness about concussion.

Providing education about concussion to teachers, administrators and their community can be as simple as providing fact sheets on concussion at school events or hanging posters in the nurses’ office. A school nurse can provide in-service trainings on concussion for staff, present information about concussion at parent-teacher meetings, or organize a community educational event on concussion. School nurses can take on an advocacy role for individual students by facilitating communication among parents, physicians, students and teachers. School nurses can also become advocates for their school districts by making suggestions for enhancement of the district’s concussion policy that would expand protocols for concussion to include grades K through 8 and protocols for concussions that occur in school but outside of sports. The school nurse can also become knowledgeable about reliable resources and websites on concussion to share with individuals and their community when there is discussion about concussion issues.

The school nurse often plays an important role in the student’s recovery from concussion.

To begin with, the nurse’s office is often used as a place for students to go for a rest break when they are tired or when other symptoms such as headache, nausea, or irritability flare up. These symptoms will usually improve if the student is able to rest in a quiet and darkened place—which may or may not be in the nurse’s office itself.

The school nurse can help to monitor the student’s symptoms and recovery.

If medication is prescribed by the student’s doctor, the nurse may help to manage medications in the school setting. Poor mental stamina and poor attention are sometimes treated with a neuro-stimulant. A variety of medications may also be prescribed to improve sleep and emotional control, or to alleviate other post-concussion symptoms.

Students who are recovering from a concussion are at increased risk for sustaining another concussion, which can worsen symptoms and hamper recovery. They will often be given a physician’s note restricting them from participating in risky sports or physical education activities for a period of time. If there is any question of possible re-injury, the student should be immediately referred for medical reevaluation.

Beyond providing the understanding that students recovering from concussion need during school hours, the school nurse is well positioned to advocate for their educational needs. She can coordinate in-service trainings for staff and facilitate communication among teachers, parents, and the student during recovery.

The school nurse may be the one professional on staff with the understanding to make the connection between recent changes in a student’s behavior, like frequent visits to the nurse’s office because of headaches, with a recent event in the gym.

A student with an unrecognized concussion may have lost friends, fallen behind in schoolwork, and/or been “in trouble” at home or in school. The school nurse can begin to gather pertinent information that could lead to identification and appropriate intervention.