Goalie Sally Egan watched as an opposing player approached her during a Saturday soccer scrimmage in February 2014. Focused on stopping the player from scoring, the 14-year-old dove for the ball just as the other girl swung her foot.
“The forward kicked me in the head,” says Sally, now a 16-year-old sophomore at Bethesda-Chevy Chase High School. “I heard ringing in my ears and I felt a little bit dizzy.”
Sally didn’t tell her coach what had happened. She knew the team’s only other goalie was sidelined with a concussion, so she figured she needed to stay in the game. After it ended, she headed to McDonald’s with friends. That’s when it became apparent that something was wrong.
“Afterwards, I was told that I was acting weird when I ordered, like they had to ask me a couple times before I responded,” says Sally, who went home and told her mom, Amy Egan, what had happened.
By the next day, Sally’s symptoms had gotten worse. She was nauseous and her head hurt, especially in a brightly lit room, and she was having trouble keeping her balance and following conversations.
Sally, who lives in Chevy Chase, stayed home from school on Monday. On Tuesday, when there was no improvement, Amy took her daughter to the pediatrician. During the visit, Sally failed a neurological exam. She couldn’t focus and nearly fell over during a simple test for balance.
“It was terrifying,” Amy says. “She couldn’t touch her nose and touch his finger, she was missing his hand entirely, and this is a kid whose hand-eye coordination has brought her all the sports success that she has experienced.”
The pediatrician diagnosed Sally with a concussion, a type of traumatic brain injury that alters the way the brain functions. It can result from a blow to the head or any type of activity that shakes the brain inside the skull. Sally was told to stay home from school for a week and do nothing that stimulated her brain so it could heal. That meant no reading or physical activity, and no screen time of any kind. It was a prescription that was difficult for Sally to follow—as it would be for most kids.
“At first it was kind of exciting because I was missing school, but then it got really boring really fast,” she says. “Not going to school was pretty tough.”
As soon as Sally’s concussion was diagnosed, strict return-to-play protocols established by her doctor and her club sports team kicked in; she wouldn’t be allowed to participate again until she was no longer experiencing symptoms. Such protocols have become common practice in children’s sports leagues and at local public and private schools.
But when Sally returned to Eastern Middle School in Silver Spring, where she was an eighth-grader in a humanities magnet program, there was no such return-to-learn protocol. Amy contacted Sally’s guidance counselor and provided a note from the pediatrician explaining that the teen might need some extra help in class.
Neuropsychologist Gerard Gioia, director of the Safe Concussion Outcome Recovery & Education Program at Children's National Health System, has treated many local children in his Rockville clinic. Photo by Jordan Silverman.
Attending school for half days at first, Sally was back in classes only a short time before she realized that she hadn’t fully recovered. Bright lights in the classroom and noise in the cafeteria would cause her head to spin.
“Math was really hard before the concussion, and then with the concussion I couldn’t focus too well,” Sally says. She found that some of her teachers were more understanding than others about her limitations. “They would excuse me from work and they’d let me have a lot of time to make stuff up.”
One teacher, though, was “pretty strict” about deadlines for a major project. So when Sally continued to suffer from symptoms after three weeks, her guidance counselor decided she needed a written plan of accommodations, known as a 504 plan, to get her more time for the project and to tell teachers what she could handle.
“The guidance counselor was amazing. I didn’t have to advocate for too much, and I attribute that to kids at that school who had come before us with concussions,” Amy Egan says.
Still, not everyone was willing to accommodate Sally while she recovered. The school's health technician, for example, would only let the teen rest in the health room for a short time. The technician said the school system’s policy required that Sally return to class or go home, Amy says, even though the pediatrician’s note said she should be allowed to rest from time to time throughout the day.
“Sally could quote you the county policy on how long she could rest in the nurse’s office,” Amy says.
Increased awareness about the dangers of concussions has prompted every state to mandate that schools educate students, parents and staff on the risks of this brain injury and devise return-to-play protocols. But the development of standards governing a student’s return to learning has lagged far behind, experts say.
In Montgomery County Public Schools (MCPS), all middle and high school student-athletes receive a packet of information about concussions and must return signed notices before they can play a school sport. Local private schools say they also have protocols for raising awareness and governing a student-athlete’s return to play.
Online testing of student-athletes to provide a baseline of their cognitive abilities before they can play also has become commonplace; MCPS requires all high school athletes to be tested. During the 25-minute test, students complete a series of timed exercises that measure verbal and visual memory, processing speed and reaction time. While the test is not used to diagnose a concussion, the baseline results can be compared to a test taken after a concussion occurs to determine how a student’s cognitive abilities have been affected.
At Georgetown Preparatory School in North Bethesda, injured student-athletes are evaluated with a number of screening tools, including the online test, athletic trainer Joe Spelta says. If a student is suspected of having a concussion, Spelta emails other school officials, including the athletic director, school nurse and assistant headmaster. “Whether or not it affects them, everybody is aware of what happened,” he says.
This school year, every MCPS high school has an athletic trainer on staff who can evaluate injured players. Bethesda parent Tom Hearn, whose son suffered a concussion four years ago as a junior varsity football player at Walt Whitman High School, lobbied the state school board to update policies concerning concussions and is credited with spearheading the drive for MCPS to hire the trainers.
When it comes to the classroom, though, schools are left to their own devices; there isn’t even a consensus among officials on who parents should contact about their child’s brain injury. MCPS Chief Communications Officer Brian Edwards says there is no standard approach because the course of action can vary depending on the severity of a student’s injury.
“All of our schools try to work with families on a very individual basis. Every child is different in the accommodations they may need and the time they may need to heal,” says Edwards, whose own daughter spent two years recovering from a concussion.
“It’s a very inexact science.”
While Edwards suggests that parents contact the principal at their child’s school, some administrators say they are more likely to tell parents to approach guidance counselors who can work with teachers to develop a plan for handling a student’s return to school. And William Beattie, MCPS director of system-wide athletics, says that once a student-athlete is diagnosed, “the school nurse becomes the hub of everything” and there is an “immediate tie-in back to the school from the athletic arena to the academic arena.”
An absence of clarity can make it difficult for parents of injured students to figure out how to make sure their children get the help they need at school while they are recovering. That’s why experts say it’s important for schools to institute standards so that families and teachers can know what to expect.
Neuropsychologist Gerard Gioia, director of the Safe Concussion Outcome Recovery & Education (SCORE) Program at Children’s National Health System in Washington, D.C., says all schools should have return-to-learn protocols that outline what types of accommodations should be provided for specific symptoms. Common arrangements include allowing a child to leave class early to rest in the nurse’s office, permission to skip certain types of assignments or cut back on homework, and providing a key to the school elevator so a child doesn’t have to climb stairs.
There also should be national standards to guide schools in how they manage students recovering from concussions, including training for staff and partnerships between schools and primary care doctors, Gioia says.
“The good news is we know a lot more about this now, we’ve got protocols,” he says. “The bad news is it hasn’t been implemented as far as it needs to be. It hasn’t been disseminated as far as it needs to be.”
Dr. Korin Hudson, an attending physician in emergency and sports medicine at MedStar Georgetown University Hospital, was hoping to increase educators’ understanding of concussions and how they affect students when she asked Walt Whitman High School Principal Alan Goodwin if she could speak to his staff this past fall.
Goodwin was happy to oblige. Like other county educators, he has been perplexed by the growing number of students who are diagnosed with concussions each year. He thinks that parents’ concerns over the long-term impact of concussions may partly explain why Whitman’s football team has dropped from about 70 players in recent years to about 40 this past season.
“What really interests me is, five years ago, certainly 10 years ago, I never heard about concussions. I never dealt with concussions,” Goodwin says. “I’ve been an educator for over 40 years and it’s never been so prevalent.”
The incidence of diagnosed concussions nationwide increased from about 9 percent of reported sports-related injuries in the 2005-2006 school year to nearly 25 percent in 2014-2015, according to the National High School Sports-Related Injury Surveillance Study by the Center for Injury Research and Policy of The Research Institute at Nationwide Children’s Hospital in Columbus, Ohio. For 10 years, the study has collected data from 100 high schools to monitor injuries among high school athletes participating in football, basketball, soccer, volleyball, softball, baseball and wrestling. Girls soccer was second only to football in the number of concussions suffered by players during the 2014-2015 school year.
Data from MCPS shows that 364 high school student-athletes were diagnosed with concussions during the 2014-2015 school year, an average of nearly 15 for each of the county’s 25 high schools. Following the national trend, football produced the most concussions at 116, followed by girls soccer with 40. Cheerleaders accounted for the third-highest number of concussions with 33, according to the data from the MCPS athletics department.
Medical experts say the growing number of diagnoses reflects increasing awareness about the impact of traumatic brain injury.
The situation is similar to what happened about 30 years ago as more research became available about attention deficit hyperactivity disorder and doctors began diagnosing more children with the condition, Gioia says.
“This is the same sort of wave that we have right now with concussions. We’re recognizing it more, we’re probably in some cases over-recognizing it, but that’s kind of the natural progression,” says Gioia, who has treated many local children at SCORE’s Rockville clinic and published numerous papers on the subject of concussions in youths.
Goodwin says he believes teachers and staff generally try to accommodate recovering students. Still, he told his staff as he introduced Hudson on a November afternoon that “one of the struggles we have is how to work with a child who has a concussion.”
Hudson, who’s also a team physician for Georgetown University athletics, treats athletes of all ages. At the time of her visit to Whitman, she was treating 12 of the school’s students. She told the staff that a concussion is “a complex process that affects the brain” and is “most like a power surge to your computer during an electric storm.” The physical and emotional changes occurring during adolescence only make it more difficult to treat concussions, she said.
“Concussions are a whole lot easier to treat in 8-, 9- and 10-year-olds, and they’re a lot easier to treat in 30- and 40-year-olds,”
Hudson told the Whitman staff. “Teenagers are tough to begin with. A teenager with a head injury is really tough.”
The “invisible” nature of the injury makes it difficult to determine what a recovering student needs when returning to school, especially for teachers and staff who haven’t been trained in what to expect and may not grasp how the stimulation of the school environment may be overwhelming, Hudson and other experts say.
That’s why several experts suggested in a December 2012 study published in the Journal of Neurosurgery that doctors, rather than sticking with the specific diagnosis of a concussion, may need to use the term “concussion spectrum” to clarify that they are referring to a number of factors that may impact the severity of a brain injury.
“There’s no way to know how severe this is or how long the symptoms are going to last based on anything we see up front,” Hudson told the Whitman staff.
Grace Wagner of Chevy Chase knows firsthand about the challenges of dealing with a long-term recovery from a concussion. In late September of seventh grade, Grace suffered a second concussion while playing soccer—not long after she’d recovered from her first.
Grace, now 15, returned to Eastern Middle School a week after she was injured, but soon was suffering from headaches and having trouble concentrating in class. Her symptoms became so debilitating as the weeks passed that she could only attend school part time before she finally had to stay home, not returning full time until April.
During the months after Grace’s injury, her mother, Laura Bowman, would tangle often with school officials over how her daughter should be accommodated—at first within the classroom and then while she recovered at home. Eventually she received a 504 plan and also was tutored at home through an MCPS program. Eastern Principal Casey Crouse declined to comment on how the school currently handles students with concussions.
Before she stopped going to school, Grace says she struggled with some teachers who weren’t willing to modify assignments or provide work that she had missed while absent. Some teachers “thought I was faking it, and that kind of really hurt me a lot because I was having such a difficult time and they weren’t making it any easier for me, and I was working really hard just to keep up,” Grace says.
Trying to keep up with classwork while recovering can be challenging enough, but what if you are a high school student facing the pressures of doing well on high-stakes exams and applying to college?
Two days before she was to take the first of four Advanced Placement exams last May, Montgomery Blair High School junior Nicole Spiezio sustained a concussion when she collided with another player during a Saturday lacrosse game. Within hours, she was suffering from headaches, light sensitivity and fatigue. “Her personality went flat,” says her mother, Chris Spiezio, of Silver Spring. “She just wanted to sleep for 14 hours.”
Chris emailed Nicole’s guidance counselor and teachers to let them know what happened. She also contacted the school’s coordinator for AP exams because it was clear that Nicole would be unable to take a chemistry exam scheduled for that Monday or the other upcoming exams. The tests were rescheduled for a few weeks later, but that meant Nicole had to take two of the most difficult three-hour exams—chemistry and calculus—on the same day.
“It’s frustrating,” Chris says of her daughter’s experience with the AP exams. “Emotionally, you are still all intact and you want to do well, but your brain is not allowing you to do well.”
In mid-October, Nicole suffered another concussion when she fell and hit her head during field hockey practice. Now a senior, Nicole was facing a Nov. 1 deadline for applying to several colleges. Her guidance counselor told her to focus foremost on completing her applications and not to worry about her classes, Chris Spiezio says.
Shortly after, though, one of Nicole’s teachers allowed students to spend a 90-minute period working on college essays on computers in a brightly lit classroom—a difficult situation for Nicole, who couldn’t focus on her work, but didn't tell the teacher she was having trouble.
Chris Spiezio says she wishes teachers had a better understanding of how a concussion can affect a student, but realizes “they’re not nurses, they’re not doctors. Their skills are to teach a class.”
School administrators say they find that teachers generally are willing to help students figure out how they can best handle the work required for a class. “We all want the same thing,” says Jennifer Baker, principal of Walter Johnson High School in Bethesda.
Some private schools, which often have more resources than public schools, will take the extra step of contacting colleges if recovering students who plan to apply may have problems taking standardized tests or meeting application deadlines.
At Bullis School in Potomac, administrators say counselors have contacted colleges to talk about prospective students recovering from concussions. “We’ve definitely had a few we had to deal with,” says athletic trainer Rachel Moore, who adds that colleges have usually been accommodating.
Lisa Heaton of Bethesda says she decided to contact Elon University in North Carolina to explain why her son Ian, then a B-CC senior, hadn’t done as well as he’d hoped on his college admission tests when he was applying for early admission in 2013. Ian had suffered a debilitating concussion while playing lacrosse in September of his sophomore year. All told, he missed four months of school, including a three-month stint during his sophomore year, and still had recurring symptoms when he took the standardized tests.
“The SATs and the ACT were a nightmare. You take a kid and sit him down for three to four hours of high-stakes testing and he did not do well,” Heaton says.
So what can schools do to better help students dealing with concussions succeed in the classroom?
Experts say educators need to understand the wide range of symptoms that students may experience and the slow nature of recovery for some. Most kids will recover from their first concussion fairly quickly; research shows that 50 percent will be better in 10 days to two weeks, with most back to normal within a month, according to Hudson. Some may have recurring symptoms for years.
“I wish there were a recipe that we could say works for everybody, but it just doesn’t [exist],” Hudson told the Whitman staff.
Still, Gioia says schools could train teams of staff to employ a standardized set of accommodations based on a student’s symptoms. The teams would include a main point of contact—usually a school nurse—for doctors, families and teachers.
Edwards of MCPS, whose daughter was treated by Gioia, acknowledges that training school staff to better understand the nature of concussions and the variable paths to recovery is a good idea. He says he has been working to connect Gioia and his team with MCPS staff.
“It’s an emerging area. A lot of teachers are not necessarily aware. It’s very difficult and challenging for teachers to understand what one child may need or another child may need,” Edwards says.
And that’s why “there ought to be a policy that can be referred to or pointed out rather than just appealing to a teacher’s goodwill or a guidance counselor’s good intentions,” notes Tom Hearn, the Bethesda parent who says he raised the issue of return-to-learn guidelines when he was lobbying for better protocols for injured athletes.
Hudson says it’s important to get kids back into the classroom as soon as possible. During her talk at Whitman, a teacher asked whether there was a baseline for determining when injured students could handle academic work, and Hudson said she recommends a step-by-step approach that takes into account the cognitive problems a student may be experiencing.
Being in class, even if students aren’t actively participating, will help facilitate their recovery, she said. So teachers should consider such accommodations as allowing a recovering student to sit up front where there are fewer distractions or assigning a “representative” amount of work, rather than the entire assignment given to other students.
“We want them back in the classroom as quickly as we can, not just for their academic performance, but also for their social and their emotional well-being,” Hudson told the Whitman staff. “It’s better than sitting at home and doing nothing.”
Julie Rasicot (julie.rasicot@bethesda magazine.com) is the managing editor of Bethesda Beat, the magazine’s daily online news briefing. She lives in Silver Spring.