PA's BrainSTEPS and PA Department of Education Concussion Teacher's Desk Reference. Fantastic compilation of what schools can do to manage student concussions immediately and follow them through the first 4 weeks of recovery until

1. Teachers’ Desk Reference:
Practical Information for Pennsylvania’s Teachers
C o n c u s s i o n u ry )
(Mild Tra u m a t i c B ra i n I n j m illion sports-
and recreatio
n-
that almost 4 ions occur every year.
erence provid es information ncuss t and
related co uring contac
This Te achers’ Desk Ref jury (TBI), specifically Concussion s can occur d s organized sports,
ic brain in a
about traumat effects of TBI o
na ctivities, such ss.
potential noncontact a , or physical education cla
concussion , and the emic perform
ance. ss ugh
avior and acad l play time, rece also occur if there is eno tly
student’s beh ters for Diseas
e Contro Concussions
can
body, withou ve
t direc
ing to the Cen uring the last decade, rce to jolt the o
Accord
ntion (CDC), d
external fo the brain to m is the
and Preve sits for sport s- and ead, causing
hitting the h e skull. An example of this of
emergency department vi ing concussions, th lt
lated TBIs, incl
ud
by rapidly inside y seatbelt restraint as a resu e
recreation-re creased db to th
adolescents in jolting cause ven an apparent mild hit
amon g children and d adolescents are among a car accid ent. E
ildren an
60 percent. Ch risk for concussion, and the
y very serious.
head can be ssion
those at great
est ry than toms of concu
recover from brain inju Sig ns and symp diately or may not
take longer to oint during your can show up
imme the
s. At som ep oncussio ns can occur or days after
adult
er, it is likely that you C
and non- appea r until hours report experi
-
teaching care t during contact any students
ast one studen es, such as injury. M
hed mental e
nergy,
will teach at le d this type of contact activiti encing diminis ively fatigued more
ne
who has sustai TBI). organized sport
s, play
becoming co
gnit ssed
traumatic brain injury (m se the concu
mild
time, rece ss, or ph ysical
easily. This is becau cover.
ork hard to re
on class. brain has to w
ptoms of educati
Signs and Sym es of sympto
ms
Concussion r main categori
There are fou ssion:
TBI is a ty pe of brain ly followin g concu
A concussion/m es the way the brain normal ering
g e nd Rememb
injury that chan ncussion is derived from th • Thinking a
co e
works. The term tere, which means, “to shak
ncu in’s cells • Physical
Latin word co cussion, the bra called
wing a con
violently.” Follo ges,
metabolic chan n,” which • Emotional
undergo chemical and f concuss io
olic cascade o s • Sleep
th e “neurometab rain function. The CDC report
al b
interrupts norm

2. Teachers, school professionals and parents should • Becomes sensitive to light or noise
be alert for any of the following signs or symptoms
• Experiences blurry or double vision
that were not present prior to the student hitting or
jolting his or her head. The presence of one symptom • Experiences ringing in the ears
can signify a concussion. • Does not “feel right”
• Experiences numbness or tingling
Symptoms Commonly Reported by School
Professionals Thinking and Remembering Changes
Initial Signs or Symptoms Observed After The student:
Trauma to the Head
• Feels confused or “foggy”
The student: • Mixes up time and/or place
• Appears dazed or stunned • Has lower attention or concentration
• Can’t recall events prior to the hit, bump, or fall • Is daydreaming more than usual
• Can’t recall events after the hit, bump, or fall • Has difficulty completing homework
• Loses consciousness (even briefly) • Has difficulty organizing thoughts, words,
• Moves clumsily materials
• Misunderstands
In-class Behaviors
• Reacts and responds slowly
The student:
• Thinks slowly
• Exhibits behavior or personality changes
• Is forgetful, has difficulty with memory
• Answers questions slowly
• Has trouble remembering to do things on
• Repeats himself/herself time
• Is forgetful • Experiences difficulty learning new concepts
• Displays confusion about daily schedule, or ideas
assignments, environment • Has difficulty making decisions
• Is unable to cope with stress or stressful events • Has difficulty planning, starting, doing, and
• Is more emotional than usual finishing a task
Emotional Changes
Symptoms Commonly Reported by
the Student The student:
• Feels restless or irritable
Physical Changes
• Is impulsive
The student:
• Becomes easily upset and/or loses temper
• Experiences a headache or “pressure” in
the head • Feels sad or depressed
• Becomes dizzy or lightheaded • Feels anxious or nervous
• Vomits or has nausea • Experiences mood swings
• Loses balance, drops things, trips • Feels more stressed than usual
• Feels worn out or exhausted, tires easily
2

3. Sleep Changes needs warrant ongoing adjustments and accom-
modations, or whether an evaluation should be
The student: conducted by the LEA to determine the need for
• Feels drowsy during the day more formal, intensive accommodations and/or
modifications. If further formal educational supports
• Sleeps less than usual
are thought to be necessary, a referral for a multi-
• Sleeps more than usual functional evaluation should be made.
• Has trouble falling asleep Once the concussed student returns to school, the
• Experiences restless sleep LEA should employ academic accommodations to
enable the student to remain successful at school.
Encouraging the student to “push through” symp-
Potential Impact on Class Performance toms, rather than managing symptoms, can prolong
Concussions/mTBIs are invisible* injuries that recovery and intensify symptom severity. Over time,
suddenly impact a student’s typical thinking, learn- it is crucial to gradually increase a student’s cognitive
ing, and behavior. Classroom teachers and school activity while monitoring the student to ensure that
nurses are often the first educational professionals he or she remains below the individual symptom
to notice these changes in a student. The symptoms threshold. For example, if the student becomes
a student experiences that impact thinking and symptomatic with an increase in cognitive activity,
recall, as well as physical and emotional well-being, cognitive activity should be reduced.
may impact the student’s academics temporarily,
and in some cases permanently. It is important to
recognize the signs of concussion and to under-
stand how to assist a student’s recovery while at
school by utilizing proper accommodations across
all settings.
The student should be medically evaluated and Annually in Pennsylvania, approximately 4,000 children
follow treatment recommended by a physician who sustain moderate to severe traumatic brain injuries,
has experience in managing concussions. This treat- which are significant enough to require hospitalization.
ment may include remaining at home on total rest Each year, over 20,000 children sustain concussions in
for the first several days after concussion occurs. The Pennsylvania. Acquired brain injuries include any injury
risk of sustaining a second concussion before the to the brain that is sustained after birth, and includes all
first concussion has healed can have devastating traumatic brain injuries (injury is caused by an external
long-term consequences, such as long-term force and includes concussions) and nontraumatic brain
disability. injuries (e.g., strokes, tumors, seizures, aneurysms).
The majority of concussions resolve within 4 weeks; Pennsylvania’s BrainSTEPS (Strategies Teaching Educators,
however, many symptoms may linger for months Parents, and Students) Brain Injury School Re-Entry
or even last a lifetime. If a student does not recover Program has been designed to consult with school teams
within the typical 4-week trajectory, the student and families in the development and delivery of educa-
should be referred to the BrainSTEPS Program for tional services for students who have experienced any
local educational agency (LEA) assistance with indi- type of acquired brain injury. BrainSTEPS is funded jointly
vidualized accommodation selection, consultation, by the Pennsylvania Department of Health and the
and training. If the student continues to remain Pennsylvania Department of Education, Bureau of Special
symptomatic past 4 to 8 weeks, the LEA should con- Education. BrainSTEPS is implemented through the
sider whether the student’s academic or behavioral Brain Injury Association of Pennsylvania to work with
tudents who have sustained a new brain injury, as well
*Concussed individuals tend to look physically normal; as with students who have been previously identified
however, each person is unique in their recovery and mani- as having a brain injury and who may begin to develop
festation of symptoms. It is important to remember one educational effects over the years as the brain matures
cannot “see” symptoms such as a headache, fatigue, light and develops.
and noise sensitivity. Continued . . .
3

4. • Standardized tests should be avoided during
BrainSTEPS the initial weeks post-concussion, while the
continued . . . student is symptomatic.
• BrainSTEPS teams are based out of the intermediate • Tests should be delayed if scheduled during
units across the state and several large school districts. the initial 1 to 2 week(s) post-concussion.
BrainSTEPS consultants are available to provide various • The student should be required to complete
brain injury presentations to educational professionals only one test or quiz per day, as tolerated.
in Pennsylvania. Training opportunities offered include:
• Rest periods in a quiet area may need to be
• Student specific brain injury training for added to the student’s daily schedule.
district teams
• Additional time should be provided for the
• LEA in-service training on all student to complete homework and
severities of acquired brain injuries and classwork.
resulting educational impacts
• All assignments should be provided to the
• BrainSTEPS consultants provide training and consulta- student in writing.
tion to school teams and families pertaining to: • Assignments should focus on essential key
• Identification and management of acquired content while student is recovering. Remove
brain injury symptoms within the school nonessential classwork/homework.
setting, utilizing accommodations and • Assignments should not be repetitious. Once
modifications a concept has been mastered, grade the work
• School re-entry planning that the student has completed. Fifty percent
of the student’s typical workload is often
• IEP and 504 development times recommended during recovery (for
example, the student would be responsible
• Intervention selection and implementation
for completing 25 of the 50 math problems
• Ongoing monitoring of students assigned).
• Provide the student with alternatives to writ-
The BrainSTEPS Program: www.brainsteps.net ten output for tests, assignments, projects.
• Encourage the student to use word banks,
timelines, calculators, and open notes/book.
Typical Accommodations Based on Sensitivity to Light, Sensitivity to Noise, and
Presenting Symptoms Headaches
The following are common concussion accom- • Allow the use of sunglasses or ball caps to
modations that should be considered during the shield light.
initial weeks of recovery to alleviate cognitive • Seat the student in a dim area of the class-
fatigue and facilitate the cognitive rest needed for room, away from windows.
recovery.
• Allow the use of headphones/earbuds to
• The student should be medically managed block noise.
by a physician who is experienced in the
management of concussions. • Temporarily excuse the student from loud
classes (e.g., music, shop, band).
• The student should not participate in physi-
cal education, sports, or physical activity • Provide a quiet environment for the student
during recess until the student is medically to eat lunch (e.g., nurse’s office, guidance
cleared. office).
• Mental work should never be substituted for • Give the student prior notice for a fire drill,
physical activity (such as during physical edu- tornado drill, etc.
cation or recess).
4

5. • Provide the student with teacher notes when • Facilitate consistent contact with the family,
notes are presented using Power Point, a pro- student, teachers and physician during
jector, or a SmartBoard. recovery.
Dizziness • Make a referral to the BrainSTEPS Program
if a student is 4 weeks post-concussion and
• Allow the student extra time to get to class is still experiencing symptoms or if the
before the halls become busy. student’s classroom performance and/or
• Ask a peer to walk with the student. attendance has been impacted. Referrals to
BrainSTEPS can be made earlier if a student
• Have a peer carry the student’s books to and
has a concussion that is not progressively
from class.
resolving during the first several weeks, or if
• Allow the student to use the elevator, the student has a history of any of the follow-
if available. ing “concussion modifiers”:
• Provide the student with teacher notes to pre- • Past concussion(s)
vent up and down shifting of the student’s
• Migraine headaches
eyes; and, have the student follow along with
a highlighter for key concept recognition. • Depression or other mental health issues
Fatigue
• Attention deficit hyperactivity disorder
(ADHD)
• Build strategic rest breaks into the student’s
schedule, not just as needed. Provide a 5 to • A learning disability
10 minute break every 30 to 45 minutes, • Sleep disorders
initially, to alleviate fatigue. Allow the student
to put his or her head down on desk or rest How to Make a BrainSTEPS Student Referral
his or her eyes. for Consultation and Training
• The student may initially require a half-day The BrainSTEPS Program works with students
modified schedule in the morning or after- who have sustained any severity of acquired brain
noon, dependent upon the level of fatigue. injury. Students can be referred to the BrainSTEPS
Program at any point until graduation, if the injury
• The student may only be able to attend
is causing educational impacts by following these
school for 1 to 2 core classes or 1 to 2 specials
steps:
initially.
1. Go to the BrainSTEPS website:
The Local Educational Agency’s Role in www.brainsteps.net
Student Recovery
2. Click on “Make a Student Referral” link on
• Ensure that teachers have a solid understand- the top right side of the page.
ing of how concussions impact classroom
performance. BrainSTEPS consultants 3. A document will open. Choose the correct
are available to conduct LEA training and BrainSTEPS Team in your region by
student-specific training. county.
• Establish an LEA response to concussion 4. Call or email the appropriate team leader
by adopting the BrainSTEPS Returning to make a student referral.
to School After Concussion: Recommended
Protocol and establishing a Concussion
Management Team with the assistance
of the regional BrainSTEPS team.
• Allow the student to use accommodations
to alleviate cognitive fatigue and facilitate
cognitive rest, so the brain can heal.
5

6. Review
As a classroom teacher, you should be aware of the • Upon return to school, it is critical that the
basic facts about concussions and mTBIs, as well as student focus on new learning and not
the physical, cognitive, and emotional signs that missed work, due to the potential for pro-
may become apparent in a student who has sus- longing recovery by inducing cognitive
tained a concussion/mTBI: fatigue.
• All concussions are serious. • Prior conditions such as attention dis-
orders, learning disorders, and emotional
• Concussions can occur without directly
disorders tend to become exacerbated by
hitting the head.
a concussion.
• Chemical and metabolic changes occur in the
• Be aware that many students with lingering
brain during a concussion, interfering with
concussion symptoms may develop symp-
normal brain activity.
toms of depression and/or anxiety.
• Most concussions (90 percent) occur without
• Pushing through concussion symptoms such
loss of consciousness.
as headache and fatigue can prolong recov-
• Concussions are not like short-term illnesses ery and increase symptom severity.
(e.g., the flu). Initially, if a student is home for
• The Pennsylvania Department of Education,
a period of time following concussion, it is to
Bureau of Special Education, in conjunction
ensure that total rest occurs. No cognitive
with the BrainSTEPS Program, has created
activity such as television, texting, video
a step-by-step Returning to School After
games, studying, homework or reading
Concussion: Recommended Protocol, which
should occur. During this acute period of
is available to assist LEAs in Pennsylvania.
total rest, teachers should not send missed
work home.
• Expecting a student with a concussion to
complete typical school work and homework
can result in a significant increase in symp-
toms and delay the recovery process.
Cognitive overload causes cognitive fatigue.
Information included in this Teachers’ Desk Reference was adapted from published work by the U.S. Department
of Health and Human Services: Centers for Disease Control and Prevention. www.cdc.gov/concussion/
HeadsUp/schools.html
For further BrainSTEPS Program information or to discuss setting up a Concussion Management Team
supported by BrainSTEPS within your district, please contact:
Brenda Eagan Brown, M.S.Ed., CBIS
Brain Injury School Re-Entry Program Coordinator
Brain Injury Association of Pennsylvania
eaganbrown@biapa.org
(724) 944-6542
6

8. COMMONWEALTH OF PENNSYLVANIA
Tom Corbett
Governor
DEPARTMENT OF EDUCATION
Ronald J. Tomalis
Secretary
Carolyn C. Dumaresq, Ed.D.
Deputy Secretary,
Office of Elementary and Secondary Education
John J. Tommasini
Director, Bureau of Special Education
Patricia Hozella
Assistant Director, Bureau of Special Education
For more information, visit the PaTTAN
website at www.pattan.net or simply
scan the QR code with a smartphone.
Vol. 4 No.1 1/13