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CPJXXX10.1177/0009922814567305Clinical PediatricsDeMatteo et al

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Clinical Pediatrics

A Balanced Protocol for Return to 2015, Vol. 54(8) 783­–792

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DOI: 10.1177/0009922814567305

Following Concussive Injury cpj.sagepub.com

Carol DeMatteo, MSc, Dip P & OT1, Kathy Stazyk, BHSc, OT Reg (Ont)1,
Lucy Giglia, MD, MSc, FRCP(C)1,2, William Mahoney, MD, FRCP(C)1,2,
Sheila K. Singh, MD, PhD, FRCS(C)1,2, Robert Hollenberg, AB, MD, FRCS(C)1,2,
Jessica A. Harper, BSc1, Cheryl Missiuna, PhD, OT Reg (Ont)1,
Mary Law, PhD, OT Reg (Ont)1, Dayle McCauley, MSc1, and Sarah Randall, BA1

Abstract
Background. Few protocols exist for returning children/youth to school after concussion. Childhood concussion can
significantly affect school performance, which is vital to social development, academic learning, and preparation for
future roles. The goal of this knowledge translation research was to develop evidence based materials to inform
physicians about pediatric concussion. Methods. The Return to School (RTS) concussion protocol was developed
following the National Institute for Health and Care Excellence procedures. Results. Based on a scoping review, and
stakeholder opinions, an RTS protocol was developed for children/youth. This unique protocol focuses on school
adaptation in 4 main areas: (a) timetable/attendance, (b) curriculum, (c) environmental modifications, and (d) activity
modifications. Conclusion. A balance of cognitive rest and timely return to school need to be considered for returning
any student to school after a concussion. Implementation of these new recommendations may be an important tool
in prevention of prolonged absence from school and academic failure while supporting brain recovery.

Keywords
child, concussion, mild traumatic brain injury, return to school, return to learn, postconcussion syndrome,
depression, anxiety

Introduction However, emotional symptoms, fatigue, and difficulty

The main occupation of childhood is participation at
school, which is vital to social development, academic
learning, and preparation for future roles. Childhood
mild traumatic brain injury (MTBI)/concussion can sig-
nificantly affect school attendance and achievement
especially when recovery is longer than expected.
Managing the symptoms (such as headaches, fatigue,
visual and auditory sensitivities, and difficulties with
attention, memory, and concentration)1-3 through pre-
scribed rest from physical and cognitive exertion has
become the “cornerstone” of recovery from concus-
sion.4 However, little guidance is available as to how
much rest is needed, how much time off of school is
recommended, and what to do when children have dif-
ficulty with school routines.
Return-to-school decisions are characteristically
based on the presence or absence of symptoms and an
overarching dogma that missing school is not acceptable.
concentrating are not always understood to be concus-
sion related5 and therefore, many children may be
returned to school too soon.6 The consequences of return-
ing to school and other activity too early can include
exacerbation of symptoms, prolonged recovery, and the
risk of sustaining another similar injury.7,8 Alternatively,
there have been instances where the recommendation of
rest postconcussion has been misinterpreted and has led
to children being away from school for months.
Prolonged absence from school may be equally as devas-
tating to the young person due to loss of academic
1
McMaster University, Hamilton, Ontario, Canada
2
McMaster Children’s Hospital, Hamilton, ON, Canada
Corresponding Author:
Carol DeMatteo, School of Rehabilitation Science, McMaster
University, 1400 Main Street West, IAHS 403, Hamilton, Ontario,
L8S 1C7, Canada.
Email: dematteo@mcmaster.ca

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784
standing, social isolation, and may contribute to depres-
sion and/or anxiety.9
Negative outcomes after concussion include (a) neu-
rocognitive deficits such as memory difficulties and
slowed reaction time; (b) postconcussive syndrome, a
prolonged recovery of more than 1 to 3 months; and (c)
development or exacerbation of depression and/or anxi-
ety. These outcomes may be debilitating and can inter-
fere with leisure and social activities, sports, school
achievement, and eventual career opportunities.10-13 The
primary goal in managing recovery from concussion is
preventing these poor outcomes.
Achieving a balance between the importance of brain
healing and the need to return to normal routines can be
challenging. Many educators and clinicians do not have
enough understanding of this condition to deal effec-
tively with children recovering from concussion.
Children are students first and athletes second. The cur-
rent focus for concussion management is to return the
child or youth to activity/sport, there has been a gap in
focusing on returning the child to school. Returning to
school should be a top priority for children and adoles-
cents experiencing concussion even more so than return
to sport. As being a student is the primary occupation of
childhood, it is very important for children to get back
into the classroom with appropriate modifications. This
can be a very delicate balance to achieve particularly
when many still believe that remaining at home due to
the perceived need for cognitive rest should be the prior-
ity approach to recovery in the postconcussive period.
The debate regarding cognitive rest combined with
emerging research results, suggest that clear recommen-
dations are needed for families, educators and clinicians
to assist in making decisions about successful return to
school that will not exacerbate symptoms and will allow
participation in social and academic activities. An
important difference exists between returning to school
and returning to learn. Although children with concus-
sive injuries may not have the cognitive ability to par-
ticipate in learning, returning to a modified school
environment represents normality and promotes a rou-
tine and supportive social environment. Similar to the
Return to Activity (RTA) protocol, pediatric concussion
management for return to school should be conservative
and individualized.14-17
The overall goal of this project was to develop evi-
dence-informed materials to educate and advise/update
physicians and other professionals about pediatric con-
cussion. This article will focus on the development of
the Return to School (RTS) protocol. A new pediatric
focused RTA protocol was developed simultaneously
and is published elsewhere.17
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Clinical Pediatrics 54(8)
Methods
Given lack of existing evidence, the development of an
RTS protocol for children was approached according to
the National Institute for Health and Care Excellence
(NICE) for guideline development.18 Short clinical pro-
tocols are designed specifically to address clinical ques-
tions and do not meet the criteria for traditional clinical
guidelines. They are developed using the same rigorous
methods as clinical guidelines but are produced within a
shortened 9- to 11-month timeline in order to address an
immediate health concern. The complete procedure is
described in DeMatteo et al (2014).17
The following NICE procedures were conducted:
1. Initial focus groups with physicians and clini-
cians determined that RTA protocol designed
specifically for children/youth with concussion
were needed.
2. Thirty registered stakeholders who were health
professionals working with children with trau-
matic brain injury (TBI), as well as public health
agencies, school representatives, parents and
children, were recruited to be part of the protocol
development/testing process.
3. The focus of the protocol was determined
through information gathered in initial meetings
with clinicians, stakeholders, and the research
team. The scope was unanimously decided to be
Return to Activity, including sport and Return to
School post-concussion.
4. A Protocol Development group was established
consisting of the 7-member research team, plus 3
pediatric neurosurgeons, 1 developmental pedia-
trician, 1 general pediatrician, and 4 occupa-
tional therapists.
5. The review question was “What is the existing
evidence to guide return to activity including
sport and school for children and youth who
have sustained a concussion?” This was
answered through a scoping review, the details
of which are available in DeMatteo et al (2014).19
It became clear that research in this field is in the
early stages of development and as a result does
not meet the standards for appraisal of evidence
set by the Centre for Evidence Based Medicine
(CEBM).20 Therefore, the levels of evidence
tables used by the Ontario Neurotrauma
Foundation (ONF) in their MTBI guidelines
were adopted to classify the literature21 (see
Table 1). A draft protocol was produced after
assembling the evidence.
DeMatteo et al
Table 1. Ontario Neurotrauma Foundation Criteria to
Grade Level of Evidence.21
Levels of Evidence
A At least 1 randomized controlled trial, meta-
analysis, or systematic review
B At least 1 cohort comparison, case studies, or
other type of experimental study (including
biomedical and animal research)
C Expert opinion, experience of a consensus
panel, or narrative review
6. Consultation was solicited from stakeholders on
the draft protocol as well as through public pre-
sentation at rounds and community meetings for
parents, coaches, schools representatives, and
clinicians.
7. The final protocol was produced.
8. The protocol was pilot tested with physicians,
schools, parents and children, public health
departments, pediatric wards, concussion clin-
ics, physician offices, and family health teams in
Central South West Ontario.
Evaluation was carried out through a baseline survey,
which collected demographic data and information
about the participants’ experience and practice with chil-
dren with concussion. Survey results of satisfaction with
and the usefulness of the protocol were collected 4
months after distribution of the protocol.
Results
Three main themes emerged from the published scoping
review19 and showed that
1. existing consensus-based adult protocols are not
appropriate for children,
2. more conservative protocols were needed for
children, and
3. protocols for children must include return to all
activity, including sport and school.
An overarching theme was that child-specific proto-
cols were needed.
Based on these themes and stakeholder opinions, a
RTS protocol was developed for use with children and
youth between 4 and 18 years of age (see Table 2) with
supporting evidence for each recommendation. The full
protocol brochure is shown in the online appendix avail-
able at http://cpj.sagepub.com/content/by/supple-mental-
data: Return to School Protocol for Children and Youth
and can be downloaded from the CanChild Web site
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785
(http://www.canchild.ca). A separate but compatible
RTA protocol was developed at the same time to provide
guidance regarding children’s return to activities outside
of school, following concussion.17
Results of Pilot Testing
Thirty-nine participants, including physicians (31%),
pediatricians (26%), allied health professionals (41%),
and educators (2%) enrolled as participants. Seventy
percent of those enrolled in the pilot reported that they
did not use any return to school guidelines in their prac-
tice at the time of enrollment.
Thirty-three of the 39 participants engaged in knowl-
edge translation activities, including a visit by the
knowledge broker (65%), a small group learning session
(20%) and a large group learning session (12%) to
review the new RTS protocol. Online survey evaluation
resulted in a response rate of 56%. The results indicated
that 95% of respondents strongly agreed that the proto-
col gave specific and clear directions to apply the RTS
recommendations. Eighty percent of respondents
strongly agreed that the materials helped with increasing
their knowledge of concussion, and 85% strongly agreed
that their confidence in treating concussed children
increased. Seventy percent strongly agreed that the pro-
tocol changed the way in which they practiced with this
population.
Part of the evaluation was to track the distribution
patterns of the protocol. Dissemination 4 months after
release of the RTS guidelines is presented in Table 3.
Qualitative feedback on the protocol was also solic-
ited from participants and includes examples such as:
Made me less of the “bad guy” when putting kids off of
school and sports. Gave me a clear approach that can be
used for all children with concussion. (Pediatricians)
CanChild website to refer for brochure is an excellent
liaison tool for schools and teachers. (Public Health Agency
Representatives)
Discussion
Based on the needs identified by stakeholders and the
results of the scoping review, a balanced approach to
return to school after concussion was developed. The
protocol specifically focuses on return to school, not just
return to learning. The premise is that it is beneficial to
have the child return to their school environment first and
then to establish when readiness for learning can occur.
Although they may not have the cognitive ability to par-
ticipate in new learning at first, the school environment
represents normality and a social environment that has
786 Clinical Pediatrics 54(8)

Table 2. Return to School Protocol.

References

Category (Biomedical Science/

Recommendation Author (Year) Level Clinical)
These stages are designed to strike a balance Majerske et al (2008)22 B Clinical
between the importance of returning to
school and brain recovery
Halstead (2013)23 C Clinical
Work with your school to put these Halstead and Walter (2010)24 C Clinical
recommendations into place Karlin (2011)9 C Clinical and Biomedical
Master et al (2012)25 C Clinical
Stage 1: Brain Rest—No School
No school for at least 1 week McCrory et al (2009)4 C Clinical
Morin (2011)26 C Clinical
Master et al (2012)25 C Clinical
Gibson et al (2013)27 B Clinical
Lots of cognitive rest (NO TV, video games, Doolan et al (2012)28 C Clinical
texting, reading) Purcell (2012)15 C Clinical
McCrory et al (2009)4 C Clinical
Halstead and Walter (2010)24 C Clinical
Cantu (1998)29 C Clinical
Schatz and Moser (2011)30 C Clinical
Arbogast et al (2013)31 B Clinical
McCrory et al (2013)32 C Clinical
Brown et al (2013)8 B Clinical
When symptom free, move to STAGE 2
  *If symptoms persist past 2 weeks, begin Halstead et al (2013)23 C Clinical
STAGE 2
Stage 2: Getting Ready to Go Back
Start this stage 2 days prior to going back to school
Begin gentle activity guided by symptoms Majerske et al (2008)22 B Clinical
(walking, 15 minutes of screen time twice Cotman et al (2007)33 C BioMed
daily, begin reading)
Master et al (2012)25 C Clinical
If symptoms worsen reduce activity Sady et al (2011)34 C Clinical
Master et al (2012)25 C Clinical
When symptom free, move to STAGE 3 Master et al (2012)25 C Clinical
   *If symptoms persist, stay in this stage for Halstead et al (2013)23 C Clinical
a maximum of two weeks and discuss
moving to STAGE 3 with your physician
or brain injury clinician
Stage 3: Back to School/Modified Doolan et al (2012)28 C Clinical
Academics Purcell (2012)15 C Clinical
Meehan et al (2011)35 C Clinical
Cantu (1998)29 C Clinical
Karlin (2011)9 C Clinical and Biomedical
Master et al (2012)25 C Clinical
This stage may last days or months Halstead et al (2013)23 C Clinical
depending on rate of recovery
Go to bed early and get lots of sleep. Have a Master et al (2012)25 C Clinical
quiet retreat space in school.
Academic Modifications:

(continued)

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DeMatteo et al 787

Table 2. (continued)

References

Category (Biomedical Science/

Recommendation Author (Year) Level Clinical)
   Timetable/attendance: Start by going for Halstead and Walter (2010)24 C Clinical
one hour, half days or every other day
McCrory et al (2013)32 C Clinical
   Curriculum: Attend less stressful classes, McCrory et al (2013)32 C Clinical
no tests, homework in 15 minute blocks
up to a maximum of 45 minutes daily
   Environment: Preferential seating, avoid Morin (2011)26 C Clinical
music class, gym class, cafeteria, taking
the bus, carrying heavy books
   Activities: Limit screen/TV time into 15
minute blocks up to 1 hour daily
When symptom free, move to STAGE 4 Doolan et al (2012)28 C Clinical
  *If symptoms persist past 4 weeks à Halstead et al (2013)23 C Clinical
Recovery Individualized Education
Plan (IEP) may be needed
Stage 4: Nearly Normal Routines
Back to full days of school, but can do less
than 5 days a week if needed
Complete as much homework as possible
and a maximum of 1 test per week
When symptom free, move to STAGE 5
Stage 5: Full Activation
Gradual return to normal routines
including attendance, homework, tests and
extracurricular activities

Important Notes

References

Category (Biomedical Science

Recommendation Author (Year) Level or Clinical)
Anxiety can be high after a brain injury. Sady et al (2011)34 C Clinical
Many children worry about school failure
and need reassurance about the temporary
accommodations.
Max et al (2012)36 B Clinical and Biomedical
Master et al (2012)25 C Clinical
Gibson et al (2013)27 B Clinical
Depression is also common during recovery Doolan et al (2012)28 C Clinical
from a brain injury, especially when the child Johnston et al (2004)37 C Clinical
is unable to be active. This may worsen McCrory et al (2009)4 C Clinical
symptom presentation or prolong recovery Laker (2011)38 C Clinical
Shrey et al (2011)39 C BioMed
Berlin et al (2006)40 B Clinical
Kontos et al (2012)41 B Clinical
Talk with the child about these issues and offer Leddy et al (2012)12
encouragement and support.

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788
Table 3. Distribution of the Return to School Protocol.
Return to School brochures 5000 Brochures Distributed: 989 downloads from CanChild Web Site as of April 2013
Family health teams 194 physicians and allied health professionals
Emergency and hospital services 292 emergency department physicians and nurses
Educators >1000 lay public, allied health, teachers and coaches
routine and support from teachers and friends with a
reassurance of recovery. This unique 5-stage protocol
(Table 2) focuses on school adaptation in 4 main areas:
(a) timetable/attendance, (b) curriculum, (c) environ-
mental modifications, and (d) activity modifications.
This new protocol is grounded in our current under-
standing of concussion recovery, which requires a grad-
uated return to all activity. Recent brain imaging studies
also support a conservative message in considering
developing brains.32,42,43 Three concepts guide the
recovery protocols for children’s postconcussive injury:
(a) prevention of harm as the goal for physical and cog-
nitive rest in the acute phase after concussion; (b) pre-
vention of harm to the developing brain, decreasing the
potential of reinjury; and (c) prevention of prolonged
symptoms and neurocognitive changes.37,44-47 Thus, it is
highly recommended that RTS stages should be fol-
lowed in conjunction with the new RTA protocol,17
which delineates separate recovery trajectories and the
course that should be followed for a gradual step-wise
return to all activity. A youth should never return to a full
school program, if he or she is only allowed to be at step
3 moderate activity in the activity protocol. Likewise, if
a youth cannot participate fully in his or her academic
program, then he or she should not be playing full con-
tact or step 6 full activity.
A conservative yet balanced approach to return to
school raises the dilemma frequently debated by concus-
sion experts and the literature of how much rest is
needed for recovery, particularly cognitive rest.48 The
consensus statement of the 3rd International Symposium
on Concussion in Sport4 defines cognitive rest as those
activities which require attention and concentration;
however, many authors have elaborated on this to incor-
porate activities such as screen time (including cell
phones), reading, school participation or homework, and
trips or visits outside of the home.25,49 Refraining from
all of these activities for the duration of symptoms may
be unreasonable for children and youth who have a pro-
longed recovery. In fact, complete cognitive rest can
result in nonadherence to recommendations.25 A more
balanced approach is essential in light of the lack of evi-
dence pertaining to cognitive rest.
The importance of cognitive rest in recovery from
concussion is now being accepted.31,49 Two recent
studies, a prospective observational cohort and a
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Clinical Pediatrics 54(8)
retrospective chart review, found that cognitive rest had a
positive impact on shortening the length of symptoms.8,49
Gibson et al,27 however, in a retrospective cohort exami-
nation of 135 children postconcussion, found that pre-
scribing cognitive rest did not demonstrate a significant
relationship with the amount of time to resolution of con-
cussion symptoms. These authors advise caution in
applying prolonged periods of rest, particularly absences
from school, which may lead to increased anxiety and
isolation. They recommended 2 to 7 days of complete
cognitive rest followed by a gradual return to school.27
The answer to how much rest is needed remains unclear;
therefore, a thoughtful and balanced approach to return-
ing children to school is sensible.
Similar to other work previously published,23,34 the
RTS protocol weighs the risks and benefits between the
child’s need for cognitive and physical rest in order to
reduce symptoms and their participation in school. It is
aligned with other graduated return to learn programs
which also advocate symptom free periods before add-
ing cognitive activity,25,26 define the types of school sup-
ports needed,3,23 and suggest systemic procedural
initiatives to help children transition successfully back
to school.23,50,51 Our RTS protocol differs by providing a
staged approach that takes into account both the typical
and atypical recovery trajectories post concussion. This
protocol conservatively applies rest in the initial phase
but then works to get the child back to school as soon as
possible. Children need normal routines and participa-
tion in meaningful activities for good quality of life52;
therefore, we have recommended that no child should be
out of school for more than 1 month and preferably less
than that.
Decline in school attendance and performance have
been reported in 30% of children postconcussion31,53
and accommodations in only 16% were found in a
sample of high school athletes with concussion.53 The
consequences of prolonged school absence and
decreased academic performance are a loss of a sense
of competence and self worth as well as increasing
anxiety about homework and school success.9,27 These
losses, compounded by anxiety and/or depression are
associated with school refusal and negative psychoso-
cial outcomes.54,55
Returning to school within the first 2 to 4 weeks post-
concussion with modifications and accommodations to
DeMatteo et al
ensure successful reintegration can ameliorate poor out-
comes, including quality of life.27,56
The importance of school in the psychosocial devel-
opment of youth cannot be understated. This RTS proto-
col was developed to address the primary symptoms that
occur in the initial phase after concussion and secondary
symptoms that may manifest due to preinjury factors.
Secondary symptoms of anxiety and depression can also
develop due to prolonged rest and withdrawal from rou-
tines and meaningful activity.48
Although empirical evidence for specific methods
and timelines for returning children to school is not yet
available, the best existing evidence was used to guide
each recommendation. This protocol (see online appen-
dix available at http://cpj.sagepub.com/content/by/sup-
plemental-data) provides a foundation for making
clinical decisions on a case-by-case basis for children
and youth who have both rapid and prolonged recovery
from concussion. These practical suggestions are meant
to prevent the recurrence or aggravation of symptoms
with the ability to individualize based on symptoms
experienced by the child.
The new pediatric 5-stage protocol is presented
with an explanation of the gradual return to school
recommendations:
Stage 1: Brain Rest—No School
In this acute stage of recovery, it is recommended that
children stay away from school for 1 week, which
allows them to get the cognitive rest needed.25,27,49 This
rest is justified by the neurometabolic cascade that
occurs after concussion, which demonstrates brain
changes lasting up to 10 days as well as the more recent
biomedical evidence.42,57 However, this does not mean
sensory deprivation or social isolation is desired or
required. When symptom free, the child can move onto
stage 2. Children whose symptoms persist past 2 weeks
are advised to move onto stage 2 at that point regardless
in order to prevent depression.12,27,33 Examples of cog-
nitive rest are provided in the protocol. Anxiety can be
heightened after brain injury and many children with
concussion worry about school failure. Reassurance
that accommodations are temporary and are used to
help them recover safely and in a timely way can help
diffuse this anxiety.58,59
Stage 2: Getting Ready to Go Back
After being away from school for several days up to 2
weeks a gentle graduated readiness program of trying
cognitive and physical activity is proposed. Specific
activities and time limits are introduced depending on
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789
symptom exacerbation. Children are permitted to begin
reading, and try two 15-minute sessions of screen time
daily as well as walking. If children remain symptom
free, they can move onto stage 3; however, if symptoms
persist, children can stay in this stage for a maximum of
2 weeks while making trial and error adjustments to
their activity levels. Those children with persistent
symptoms over 2 weeks’ duration should consult their
physician or experienced brain injury clinician in pro-
gressing to stage 3. It may be unrealistic to expect a
child to stay out of school until symptom free so man-
agement of chronic symptoms without increasing symp-
toms while returning to school becomes the focus.
Stage 3: Back to School/Modified Academics
Stage 3 is where many children with prolonged symptoms
remain for weeks or months, depending on the individual
rate of recovery. In this stage it is important to maintain a
proper sleep schedule that includes going to bed early and
getting an adequate amount of sleep.25 School and aca-
demic modifications are grouped into 4 types:
1. Timetable or attendance, which advocates a
gradual reintegration with examples of starting
out hourly with the most severely symptomatic,
to half days or 2 full days combined with half
days or whatever combination works for that
child.
2. Curriculum adjustments, which include negoti-
ating with the student and school personnel
which and how many classes to attend. This
often depends on the cognitive stress load of
individual subjects. The child to whom math
comes easily yet French is highly difficult would
participate in math initially and not French.
There should be no homework initially but grad-
ually move to homework done in 15-minute
blocks up to a maximum of 45 minutes daily
depending on aggravation of symptoms.
3. Environmental accommodations, which could
include introduction of a quiet retreat space,
preferential seating and avoiding busy, noisy
areas within the school. Some children will need
to wear dark glasses for light sensitivity or ear-
phones to dull the auditory stimuli but still con-
tinue to participate in class activities.
4. General activity modifications include contin-
ued limitations on screen time, including TV,
computers, and smart phones in 15-minute
blocks up to 1 hour daily. Similar to previous
stages, if children remain symptom free they can
move onto stage 4; however, if symptoms persist
790
beyond 4 weeks, a recovery Individualized
Education Plan (IEP) that will formalize these
accommodations is recommended.23
Stage 4: Nearly Normal Routines
The successful transition into stage 4 includes return to
full days of school but the child can do less than 5 days
a week if needed. The ability to be able to attend full
days as well as complete as much homework as required
is the main goal in stage 4. The protocol encourages that
the child should only write 1 test per week. A complete
resolution of postconcussive symptoms results in
advancing to stage 5.
Stage 5: Fully Back to School
The final phase of the graduated return to school proto-
col involves returning to normal school routines, includ-
ing consistent attendance, regular completion of
homework and tests, participation in extracurricular
activities, and riding the school bus.
Returning children and youth to their school routines
and academic success is an important part of recovery
from concussion. It must be done with scientific evi-
dence, sound clinical judgment and full participation of
the school and family in every step of the process.
Limitations
The main limitation to developing this protocol is that
there is little research evidence; therefore, the protocol
development team had to extrapolate from the biomedi-
cal research and adult consensus information to inform
the recommendations as written. However, a scientific
method was followed to develop the service recommen-
dations, which included consensus and pilot testing of
the protocol.
Conclusion
A balance of cognitive rest and timely return to school
need to be considered in a protocol for returning any
student to school after a concussion. This newly devel-
oped Return to School protocol was found to be easily
understood and popular with families, educators, and
medical and allied health professionals working with
children with concussion. Implementation of these new
school-specific recommendations may be an important
tool in prevention of prolonged absence from school and
academic failure while still supporting postconcussive
brain recovery. Anxiety and depression may result if a
child is deprived of their main occupation, being a
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Clinical Pediatrics 54(8)
student in the social environment of a school. The next
stage is to evaluate whether adherence to this protocol
positively affects child and youth health outcomes after
concussion.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) disclosed receipt of the following financial sup-
port for the research, authorship, and/or publication of this
article: This study was supported by the Canadian Institute of
Health Research (CIHR; grant number 115228).
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2. Sim A, Terryberry-Spohr L, Wilson KR. Prolonged recov-
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3. Kirkwood MW, Yeates KO, Taylor HG, Randolph C,
McCrea M, Anderson VA. Management of pediatric mild
traumatic brain injury: a neuropsychological review from
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