http://informahealthcare.com/bij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, 2015; 29(1): 64–77 ! 2015 Informa UK Ltd. DOI: 10.3109/02699052.2014.965747

ORIGINAL ARTICLE

Paediatric concussion: Knowledge and practices of school speech-language pathologists Melissa C. Duff1,2, & Sarah Stuck1 1

Department of Communication Sciences and Disorders and 2Department of Neurology, Division of Cognitive Neuroscience, University of Iowa, Iowa City, IA, USA Abstract

Keywords

Primary objective: To characterize paediatric concussion knowledge and the management practices of school-based speech-language pathologists (SLPs) in the US to establish a baseline upon which changes in SLP training, knowledge and best practices can be measured. Research design: A survey was developed to assess current knowledge and management of paediatric concussion allowing for comparison to previous and future surveys on SLP knowledge and practice in other areas of brain injury. Methods and procedures: One thousand surveys were distributed to school-based SLPs from 10 states. Two hundred and eighty SLPs from Minnesota, Wisconsin, New York, Massachusetts, Georgia, Florida, Texas, Tennessee, California and Arizona responded to the survey. Main outcomes and results: Compared to previous survey results, SLPs from the current sample indicate an increase in general brain injury training, but confidence in providing clinical services to brain-injured students remains low. SLPs have a mix of accurate and inaccurate concussion knowledge and uncertainty about their role in concussion management. Conclusions: Findings suggest that increasing communication with other school personnel about concussion, increased training in paediatric TBI and concussion improved access to appropriate assessments tools and implementation of long-term concussion management will improve service delivery to school-aged children with concussion.

Assessment, concussion, management, mild traumatic brain injury, speech language pathology

Introduction Traumatic brain injury (TBI) is a global public health issue, with the incidence of TBI rising worldwide [1]. In recent years there has been increased attention to brain injuries that are considered mild, such as concussions. In fact, concussion management is considered the fastest growing sub-discipline of neuropsychology and the literature of concussion management is growing exponentially [2–4]. While it is difficult to get accurate international estimates of concussion rates [1], estimates of US recreation and sports-related concussion are between 300 000–3.8 million injuries annually [5, 6]. Over the past 20 years, accumulating evidence suggests that, while most individuals make a full recovery from mild brain injuries such as concussions, some individuals experience significant and persistent cognitive-communication impairments including behavioural, social and emotional deficits that negatively impact academic achievement and social interactions [7–11]. In recognition of these potential persistent deficits and the wealth of new empirical concussion data, there has been an international effort to establish consensus positions and recommendations to improve concussion management [12–14]. Correspondence: Melissa C. Duff, PhD, Department of Communication Sciences & Disorders, 250 Hawkins Drive, University of Iowa, Iowa City, IA 52242, USA. Tel: 319-384-4702. E-mail: melissa-duff@ uiowa.edu

History Received 22 February 2014 Accepted 11 September 2014 Published online 10 October 2014

These advances in concussion knowledge and management present a unique set of challenges and opportunities for those providing clinical or educational services to children at risk for or who have sustained a concussion. In school settings, speech-language pathologists (SLPs) are among the primary service providers for children with brain injury. Individuals who have sustained a brain injury qualify for special education services like speech-language pathology under the Individuals with Disabilities Education Act (IDEA), a federal law that guarantees special education services for students with disabilities such as TBI [15]. Both the scope of practice [16] and the position statement on cognitive-communication disorders [17] from the American Speech-Language-Hearing Association highlight the role and responsibilities to individuals following a head injury. Furthermore, Duff [18] argued that SLPs are among the most qualified in school settings to meet the demands of detecting and managing concussion given their knowledge of cognitive-communication disorders, administration of standardized testing and clinical decision-making. This is particularly the case in schools where there is not a staff neuropsychologist. Salvatore and Fjordback [19] agree, stating that school-based SLPs are the best suited to provide these services, as they are ‘strategically located to care for and monitor the neurocommunication and academic progress’ (p.2) of students with a concussion.

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Yet, numerous studies have documented that educators and SLPs feel unprepared and lack confidence to deliver services to individuals with TBI [20–24]. The lack of preparedness has been linked to a minimal amount of coursework in cognition [20, 25] and lack of supervised clinical experience in graduate training programmes [21]. Similarly, in a study of 78 Illinois school-based SLPs, Duff et al. [26] found that SLPs do not feel qualified or prepared to provide service to students with TBI, to serve on an interdisciplinary brain injury team or to educate other school personnel and student athletes about the consequences and prevention of concussion, although they stated that doing so was within their scope of practice and a role that SLPs should embrace. While it seems clear that the range of cognitive deficits possible following a concussion could interfere with language and communication, placing them on the caseload of the school speech-language pathologist [25], the role of SLPs in concussion management and current practices for school-aged children with concussion has not been described. The goals of the current survey study were: (1) to determine and characterize the current knowledge of paediatric concussion in school SLPs including the causes, symptoms and neuropathophysiology of concussion; the effects of age and multiple injuries on concussion recovery; and the impact of concussion on cognition, communication, social and academic performance; (2) to determine and characterize the current management practices for students with a concussion by school SLPs including obtaining information about the number of students with concussion on their caseload, assessment and treatment procedures used for this population, frequency of follow-up or monitoring services of students with a history of concussion and role in concussion education and prevention. The results promise to offer insights about current practice, lead to more targeted education opportunities for practicing SLPs and identify future research needs. They may ultimately improve the quality of service delivery to students recovering from concussion.

Methods Survey development A survey consisting of 64 items to assess knowledge and current management of children with concussion was developed and served as the basis for data collection (see Appendix A). Survey items addressed seven areas: professional background information, concussion knowledge and terminology, referral, assessment, management, follow-up and/or monitoring and respondents’ education and experiences with TBI and concussion. Survey questions were a mix of multiple choice, fill-in, yes/no and Likert-type scale formats. A 5-point scale accompanied all Likert-type items, ranging from ‘strongly agree’ to ‘strongly disagree’, with a mid-point response of ‘uncertain’. Professional background items included four questions concerning the respondents’ education and current employment. Concussion knowledge and terminology was divided into two parts: (a) 16 statements concerning epidemiology, characteristics, behaviours, assessment and treatment procedures to which respondents indicated their level of agreement on a 5-point Likert scale; and (b) 10 terms associated with

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concussion and TBI to which respondents indicated whether or not they were capable of providing definitions by answering yes or no. The content for the concussion knowledge section was established by reviewing literature on concussion. Items included in the referral section focused on whether or not respondents were notified when students sustain a concussion at or away from school. In the assessment section, respondents provided information about the frequency and type of assessment (e.g. formal and informal assessments; areas of assessment) for students with concussion. In the management section, respondents provided information about frequency and type of treatment, classroom modification, education or awareness of concussion and their opinions about and readiness to provide services to students with concussion. The section on followup and/or monitoring procedures addressed current practices for re-assessment and follow-up. For these three sections of the survey (assessment, management and follow-up and/or monitoring), respondents were instructed to answer the questions based on their current practices. If they have never provided concussion services, respondents were asked to answer the question based on how they would approach the situation. Questions about education and experiences with TBI and concussion covered training specific to concussion and TBI, history of service delivery in a medically-based setting and if their school district has a head injury team. The content of the survey items came from a systematic review of the literature and incorporated some questions from previous surveys on the roles and knowledge of SLPs in the area of brain injury [21, 23, 26]. To determine face validity, the survey was distributed to four practicing SLPs and four graduate students for review and input. Revisions were made to the wording of ambiguous questions and to the organization of the final survey. Redundant questions were removed. Participants A total of 1000 surveys were mailed to practicing school speech-language pathologists across 10 states: Minnesota, Wisconsin, New York, Massachusetts, Georgia, Florida, Texas, Tennessee, California and Arizona. Using data from the 2010 Schools Survey report [27], the 10 states were selected as they: (a) represent diverse geographical regions of the US and (b) represent the density of speech-language pathologists practicing in various geographic areas (e.g. highest percentage of speech-language pathologists working in the South (30%); smallest in the West (18%)). The names and addresses of the participants were obtained from the American SpeechLanguage-Hearing Association. For each state, a mailing list containing the names of 100 randomized SLPs self-designated as working in elementary, middle/junior high and/or high school was obtained. Two weeks after mailing the survey with the original invitation to participate, reminder postcards were mailed to all 1000 individuals, encouraging the completion and return of the survey. Response rate A total of 280 surveys were returned, which is a 28% response rate. The number of responses from the 10 states ranged from a low of 20 (New York) to a high of 37 (Minnesota)

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(M ¼ 27.2; SD ¼ 5.2). A total of 272 surveys were used for data analysis. Of the 280 returned, eight surveys were not used in data analysis either because the respondent indicated they had never worked in a school setting or the survey was returned blank. Data analysis The sample size varied across questions on the survey, as not all respondents answered all questions. Survey data were treated descriptively. The survey contained 16 statements concerning epidemiology, characteristics, behaviours, assessment and treatment procedures of concussed students to which respondents indicated their level of agreement on a 5-point Likert scale. Following Hux et al. [23], responses were collapsed to provide a general indication of agreement or disagreement with a given statement. Responses of strongly agree and agree as well as strongly disagree and disagree were combined for the purpose of data analysis.

Brain Inj, 2015; 29(1): 64–77

Table I. Percentage of respondents with concussion training and source of training (n ¼ 264).

State AZ (n ¼ 31) CA (n ¼ 27) FL (n ¼ 25) GA (n ¼ 23) MA (n ¼ 22) MN (n ¼ 37) NY (n ¼ 19) TN (n ¼ 25) TX (n ¼ 23) WI (n ¼ 32) Total (n ¼ 264)

The number of years respondents worked as a speechlanguage pathologist at the time of completing the survey ranged from 2–43 years (M ¼ 16.5; SD ¼ 9.51). The overwhelming majority of respondents held a master’s degree (97.77%; n ¼ 263/269), while 1.49% (4/269) held a doctoral degree and less than 1% held only a bachelor’s degree (n ¼ 2/ 269). The majority of respondents worked in elementary schools (70.8%; n ¼ 245/332). About 18% (n ¼ 60/332) worked at a junior high or middle school and 11.1% (n ¼ 37/332) worked at a high school. Over half (61.3%; n ¼ 160/261) of respondents reported full-time employment at a single school, while 38.7% (n ¼ 101/261) of respondents provided services at more than one school. Respondents indicated that few schools or school districts in the states surveyed have interdisciplinary brain injury teams (10.6%; n ¼ 27/255). Of the schools with brain injury teams, 29.6% (n ¼ 8/27) of respondents participated on the team. Although this study was specifically interested in the concussion management practices in the schools, it is interesting to note that over half of the respondents (57.1%; n ¼ 153/268) have previously provided services in a medically-based setting (e.g. hospital). Only 21.2% (n ¼ 56/264) of respondents had specific training related to concussion and less than half of respondents with this training (41.2%; n ¼ 14/34) completed clinical practice with individuals with concussion. Of those respondents who indicated receiving training in concussion, 41.1% (n ¼ 23/56) did so as part of continuing education, 33.9% (n ¼ 19/56) did so as part of their undergraduate or graduate school training and 25% (n ¼ 14/56) received both college and continuing education training. Some differences in concussion training emerged among the states sampled (see Table I). Arizona had the most respondents who reported having concussion training (38.7%; n ¼ 12/31), while New York, with 15.8% of respondents (n ¼ 3/19), had the fewest number of respondents who reported concussion training. The source of concussion training was variable across states.

38.7% 25.9% 16.0% 8.7% 18.2% 21.6% 15.8% 20.0% 17.4% 21.9% 21.2%

College

Continuing education

Both college and continuing education

8.3% 71.4% 50.0% 50.0% 0.0% 37.5% 33.3% 20.0% 75.0% 28.6% 33.9%

58.3% 28.6% 25.0% 50.0% 75.0% 37.5% 66.7% 20.0% 0.0% 42.9% 41.1%

33.3% 0.0% 25.0% 0.0% 25.0% 25.0% 0.0% 60.0% 25.0% 28.6% 25%

Table II. Percentage of respondents with TBI training and source of training (n ¼ 265).

Results Education and experiences

Concussion training

State AZ (n ¼ 31) CA (n ¼ 28) FL (n ¼ 24) GA (n ¼ 23) MA (n ¼ 23) MN (n ¼ 36) NY (n ¼ 20) TN (n ¼ 25) TX (n ¼ 23) WI (n ¼ 32) Total (n ¼ 265)

TBI training 83.9% 92.9% 70.8% 91.3% 78.3% 88.9% 85.0% 84.0% 82.6% 78.1% 83.8%

College

Continuing education

Both college and continuing education

23.1% 30.8% 17.6% 42.9% 50.0% 56.3% 52.9% 42.9% 31.6% 48.0% 40.6%

26.9% 3.8% 23.5% 14.3% 5.6% 3.1% 11.8% 9.5% 21.1% 12.0% 12.8%

50.0% 65.4% 58.8% 38.1% 44.4% 40.6% 35.3% 47.6% 42.1% 36.0% 46.6%

Over two-thirds of respondents from California, Texas, Tennessee and Florida reportedly received concussion training as part of college coursework. Over two thirds of respondents from New York, Massachusetts, Wisconsin and Arizona received concussion training through continuing education. While the number of respondents receiving training specific to concussion was low, the majority of respondents had received more general training in TBI. Over 80% of respondents had training related to TBI (83.8%; n ¼ 222/265) and 73.1% (n ¼ 136/186) performed clinical practica with individuals with TBI. Similar to the data on concussion training there was considerable variability among the states (see Table II). California had the most respondents reporting TBI training (92.9%; n ¼ 26/28), while Florida had the fewest respondents reporting TBI training (70.8%; n ¼ 17/24). The source of TBI training was more consistent across respondents, as over 70% of respondents from all states received TBI training as part of college coursework. Concussion knowledge The survey contained 16 statements concerning epidemiology, characteristics, behaviours, assessment and treatment procedures to which respondents indicated their level of agreement. Over 80% of respondents disagreed that loss of

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Table III. Concussion knowledge of respondents. Statement

Agree

Uncertain

Disagree

Loss of consciousness is required for a diagnosis of concussion (n ¼ 271) A concussion is a brain injury (n ¼ 271) Children show better recovery from concussion than older individuals (n ¼ 271) The signs and symptoms of concussion can overlap with symptoms of other disorders such as depression, anxiety and attention-deficit disorder (n ¼ 272) Recovery from concussion is complete when the individual is asymptomatic (n ¼ 272) Concussion makes an individual more vulnerable for a subsequent injury (n ¼ 272) Concussion can affect academic performance (n ¼ 272) Cognitive rest is important for recovery from a concussion (n ¼ 272) Physical rest is important for recovery from a concussion (n ¼ 270) A standardized protocol, or return to play guidelines, is important for determining when a student returns to competitive play (n ¼ 269) Individualized baseline neuropsychological testing for student athletes is part of concussion prevention and management (n ¼ 269) Concussed students are eligible for accommodations such as specialized instruction or other educational accommodations (n ¼ 270) Concussions result in structural damage that is visible on CT or MRI scans (n ¼ 267) Multiple concussions are required to observe long-term cognitive deficits (n ¼ 268) Concussions can occur in individual or group recreational sport or activity (n ¼ 268) A repeated concussion that occurs before the brain recovers from the first can slow recovery or increase the likelihood of having long-term problems (n ¼ 268)

7.38% 92.62% 61.03% 75.00%

12.55% 4.80% 31.25% 21.69%

80.07% 2.58% 7.72% 3.31%

5.88% 80.15% 96.32% 44.85% 89.26% 81.41%

21.69% 14.71% 3.31% 36.03% 8.52% 15.24%

72.43% 5.15% 0.37% 19.12% 2.22% 3.35%

37.17%

47.96%

14.87%

53.33%

32.96%

13.7%

29.21% 8.58% 98.88% 94.40%

43.45% 23.51% 1.12% 5.22%

27.34% 69.91% 0% 0.37%

Table IV. Influence of TBI training on respondents’ concussion knowledge. Training

No Training

Statement

Agree

Uncertain

Disagree

Agree

Uncertain

Disagree

Loss of consciousness is required for a diagnosis of concussion. A concussion is a brain injury. Children show better recovery from concussion than adults. The signs and symptoms of concussion can overlap with symptoms of other disorders such as depression, anxiety and attention-deficit disorder. Recovery from a concussion is complete when the individual is asymptomatic. Concussion makes an individual more vulnerable for a subsequent injury. Concussion can affect academic performance. Cognitive rest is important for recovery from a concussion. Physical rest is important for recovery from a concussion. A standardized protocol or return to play guidelines is important for determining when a student returns to competitive play. Individualized baseline neuropsychological testing for student athletes is part of concussion prevention and management. Concussed students are eligible for accommodations such as specialized instruction or other educational accommodations. Concussions result in structural damage that is visible on CT or MRI scans. Multiple concussions are required to observe long-term cognitive deficits. Concussions can occur in individual or group recreational sport or activity. A repeated concussion that occurs before the brain recovers from the first can slow recovery or increase the likelihood of having long-term problems.

7.3% 92.8% 60.6% 75.1%

14.7% 4.5% 31.2% 21.7%

78.0% 2.7% 8.1% 3.2%

7.0% 90.7% 62.8% 76.7%

4.7% 7.0% 30.2% 18.6%

88.4% 2.3% 7.0% 4.7%

5.5% 81.1% 95.9% 45.5% 81.0% 89.6%

21.0% 13.1% 3.6% 36.8% 15.4% 7.7%

73.5% 5.9% 0.5% 17.7% 3.6% 2.7%

9.3% 74.4% 97.7% 41.9% 83.3% 86.0%

23.3% 23.3% 2.3% 32.6% 14.3% 14.0%

67.4% 2.3% 0.0% 25.6% 2.4% 0.0%

37.9%

47.0%

15.1%

28.6%

54.8%

16.7%

53.9%

32.0%

14.2%

48.8%

39.5%

11.6%

30.3% 10.1% 98.6% 93.2%

42.2% 22.6% 1.4% 6.4%

27.5% 67.3% 0.0% 0.5%

23.8% 0.0% 100% 100%

47.6% 27.9% 0.0% 0.0%

28.6% 72.1% 0.0% 0.0%

consciousness is required for a diagnosis of concussion. Additionally, over 80% agreed that a concussion is a brain injury, an individual who has sustained a concussion is more vulnerable for a subsequent brain injury, concussion can affect academic performance, physical rest is important for recovery, concussions can occur in any recreational sport or activity and repeated concussions can cause long-term damage if the brain does not recover between injuries. Some uncertainty emerged for several of the statements. Over 20% of respondents were uncertain if children show better concussion recovery than adults, signs and symptoms of concussion overlap symptoms of other disorders, concussed students are eligible for educational accommodations, recovery is complete when the individual is asymptomatic or multiple concussions are required to observe long-term cognitive

deficits. Over 35% of respondents were unsure if cognitive rest is important for recovery, individual baseline neuropsychological testing is part of concussion prevention and management or concussions result in structural damage visible on MRI or CAT scans. Concussion knowledge of respondents is displayed in Table III. Overall, TBI training did not appear to significantly impact respondents’ concussion knowledge. TBI training was defined as undergraduate or graduate coursework and/or continuing education such as in-services, workshops, conferences and seminars. Responses to concussion knowledge questions were similar for individuals with and without TBI training. The responses of the entire group were similar to those of individuals with TBI training. Table IV displays the influence of TBI training on respondents’ concussion knowledge.

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Table V. Influence of concussion training on respondents’ concussion knowledge. Training

No Training

Statement

Agree

Uncertain

Disagree

Agree

Uncertain

Disagree

Loss of consciousness is required for a diagnosis of concussion. A concussion is a brain injury. Children show better recovery from concussion than adults. The signs and symptoms of concussion can overlap with symptoms of other disorders such as depression, anxiety and attention-deficit disorder. Recovery from a concussion is complete when the individual is asymptomatic. Concussion makes an individual more vulnerable for a subsequent injury. Concussion can affect academic performance. Cognitive rest is important for recovery from a concussion. Physical rest is important for recovery from a concussion. A standardized protocol or return to play guidelines is important for determining when a student returns to competitive play. Individualized baseline neuropsychological testing for student athletes is part of concussion prevention and management. Concussed students are eligible for accommodations such as specialized instruction or other educational accommodations. Concussions result in structural damage that is visible on CT or MRI scans. Multiple concussions are required to observe long-term cognitive deficits. Concussions can occur in individual or group recreational sport or activity. A repeated concussion that occurs before the brain recovers from the first can slow recovery or increase the likelihood of having long-term problems.

3.6% 98.2% 58.2% 90.9%

14.5% 1.8% 25.5% 9.1%

81.8% 0.0% 16.4% 0.0%

8.1% 91.4% 61.0% 70.5%

11.5% 5.3% 33.3% 25.2%

80.4% 3.3% 5.7% 4.3%

5.5% 90.9% 100% 54.5% 81.8% 94.5%

14.5% 7.3% 0.0% 30.9% 12.7% 3.6%

80.0% 1.8% 0.0% 14.5% 5.5% 1.8%

6.2% 77.1% 95.2% 42.4% 81.7% 88.0%

23.3% 16.7% 4.3% 37.6% 15.4% 9.6%

70.5% 6.2% 0.5% 20.0% 2.9% 2.4%

38.2%

41.8%

20.0%

35.6%

50.5%

13.9%

72.7%

16.4%

10.9%

47.4%

37.8%

14.8%

29.6% 1.9% 100% 98.1%

29.6% 11.1% 0.0% 1.9%

40.7% 87.0% 0.0% 0.0%

28.5% 10.6% 98.6% 93.3%

46.9% 25.5% 1.4% 6.3%

24.6% 63.9% 0.0% 0.5%

In contrast, concussion training increased respondents’ concussion knowledge across most areas. Concussion training was defined as undergraduate or graduate coursework and/or continuing education such as in-services, workshops, conferences or seminars. Ninety-one per cent of respondents (n ¼ 50/55) with concussion training indicated that signs and symptoms of concussion can overlap with those of other disorders compared to only 70% of respondents without concussion training. Over 70% of respondents (72.7%; n ¼ 40/ 55) with concussion training indicated that concussed students are eligible for accommodations such as specialized instruction or other educational accommodations. Similar to the group as a whole, respondents with concussion training remained unsure if cognitive rest is important for recovery (30.9%; n ¼ 17/55), if concussions result in structural damage visible on CT or MRI scans (29.6%; n ¼ 16/54) and if children show better recovery than adults (25.5%; n ¼ 14/55). Table V displays the influence of concussion training on respondents’ concussion knowledge. Survey respondents were asked to give a yes/no response on their ability to define 10 words associated with concussion and TBI. Over 70% of respondents indicated an inability to define the following terms: second impact syndrome, diffuse axonal injury and anterograde amnesia. On the other hand, at least 75% of respondents believed they could define posttraumatic amnesia, executive functioning and consciousness. Respondents were divided on their perceived ability to define Glasgow Coma Scale, lability, confabulation and retrograde amnesia. Table VI shows results of this section.

Table VI. Perceived ability to define concussion and TBI terms. Term Executive functioning (n ¼ 267) Consciousness (n ¼ 266) Post-traumatic amnesia (n ¼ 269) Lability (n ¼ 266) Glasgow Coma Scale (n ¼ 268) Retrograde amnesia (n ¼ 266) Confabulation (n ¼ 265) Second impact syndrome (n ¼ 266) Anterograde amnesia (n ¼ 266) Diffuse axonal injury (n ¼ 268)

Yes

No

94.01% 93.61% 79.55% 59.02% 57.84% 48.50% 41.51% 27.44% 27.07% 20.15%

5.99% 6.39% 20.45% 40.98% 42.16% 51.50% 58.49% 72.56% 72.93% 79.85%

notified when a student sustains a concussion at or away from school. Only 34.6% (n ¼ 56/162) indicated knowing which school personnel are notified when a student has a concussion. Respondents reported that the school nurse (n ¼ 49/96; 51%), administrators (n ¼ 17/96; 18%) and teachers (n ¼ 17/ 96; 18%) are the ones notified when a student sustains a concussion at or away from school. Of those who are notified when a student sustains a concussion, the majority reported receiving 1–5 referrals per year (95.2%; n ¼ 20/21) and one respondent indicated receiving 5–15 referrals per year (4.8%; n ¼ 1/21). Respondents indicated that it is the parent (n ¼ 20/65; 31%), teacher (n ¼ 18/65; 28%) or school nurse (n ¼ 15/65; 23%) who notifies the SLP when a student sustains a concussion. These referrals are typically received within 1–7 days of the injury (54.6%; n ¼ 12/22).

Referral Only 11.7% (n ¼ 31/265) of respondents indicated that they are notified when a student in their school sustains a concussion at or away from school. Of the respondents who are not notified, 80.6% (n ¼ 129/160) believe they should be

Assessment Respondents were asked to indicate which areas should be assessed for a student who has sustained a concussion. Respondents provided 41 unique areas to assess

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(357 total responses). Expressive language was the most frequently reported area to assess (21.3%; n ¼ 76/357) followed by receptive language (20.7%; n ¼ 74/357) and memory (9.8%; n ¼ 35/357). Other areas of assessment included pragmatics (7%), word retrieval (4.2%), problemsolving (3.9%), executive functioning (3.6%), auditory processing (3.4%), attention (2.2%) and language comprehension (2.0%.) Areas of assessment receiving less than 2% of responses are not reported. A small percentage of responses (2.2%; n ¼ 8/357) indicated uncertainty of which area(s) to target in assessment. Less than 10% of respondents (6.4%; n ¼ 17/270) have assessed a student following a concussion. Respondents provided 55 unique responses (326 total responses) when asked to indicate a formal assessment used to evaluate students with concussion. The Clinical Evaluation of Language Fundamentals (CELF) was the most frequently reported formal assessment tool (17.5%; n ¼ 57/326) followed by the Comprehensive Assessment of Spoken Language (CASL) (5.5%; n ¼ 18/326) and the Expressive One-Word Picture Vocabulary Test (EOWPVT) (4.3%; n ¼ 14/326). Other assessment tools reported included the Test of Auditory Processing Skills (TAPS) (3.4%), the Peabody Picture Vocabulary Test (PPVT) (3.1%), the Receptive OneWord Picture Vocabulary Test (ROWPVT) (2.8%), the Test of Language Development (TOLD) (2.5%), the Test of Problem Solving (TOPS) (2.5%) and the Oral and Written Language Scale (OWLS) (2.1%). Assessment tools receiving less than 2% of responses are not reported. Nearly a quarter of the responses (22.4%; n ¼ 73/326) were not specific formal assessment tools but rather described a test category such as a language assessment or memory assessment. Seven per cent (n ¼ 23/326) of responses indicated the respondents were unsure or would need to research for a proper formal assessment. A small percentage of responses (4%; n ¼ 12/326) indicated that someone else in the school or district would do the assessment. Respondents were also asked to indicate informal assessment tools or measures used for students with concussion. Respondents provided 53 unique responses (349 total responses). A parent, teacher or coach interview following a concussion was the most commonly reported informal assessment (14%; n ¼ 49/349) followed by classroom observation (12.6%; n ¼ 44/349) and language sample (10.6%; n ¼ 37/349). Other responses for commonly used informal assessment included student interview (8.9%) and short-term memory (4.3%). Three per cent (n ¼ 12/349) reported uncertainty as to what formal assessment to use. Management Less than 10% of respondents (9.7%; n ¼ 26/267) reported having experience providing services for a student with a concussion. Respondents provided 51 unique areas to target in treatment (320 total responses). Memory was the most frequent response (14.7%; n ¼ 47/320) followed by expressive language (9.1%; n ¼ 29/320) and word retrieval (7.5%; n ¼ 24/320). Respondents also included executive function (5.9%), receptive language (5.6%), auditory processing (5.3%), pragmatics (5.3%) and organization (5.0%). Five per

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cent of responses (n ¼ 16/320) indicated that any deficit area would be treated and 4.7% (n ¼ 15/320) stated uncertainty as to which area to target in treatment of concussed students. Areas to target in treatment that received less than 4% of responses are not reported. Respondents were asked how long a concussed student would stay on the caseload to receive treatment. The most common treatment durations were more than a year (25.6%; n ¼ 20/78), 1–3 months (24.4%; n ¼ 19/78) and 4–6 months (20.5%; n ¼ 16/78). When asked to list classroom accommodations for students with concussion, respondents provided 42 unique strategies and modifications (451 total responses). The most common classroom accommodation reported was extended time for work and tests (13.7%; n ¼ 62/451) followed by repetition of directions/questions (10.6%; n ¼ 48/451) and more visual cues/aids (10%; n ¼ 45/452). Other accommodations reported included preferential seating (9.1%), modified workload (8.4%), note-taking help/study guides (6.4%), breaks throughout the day (4.7%) and teacher checks for student understanding (4.2%). Accommodations that received less than 4% of responses are not reported. About 2% of respondents (n ¼ 10/451) indicated uncertainty of appropriate classroom accommodations and another 2% (n ¼ 9/451) stated that accommodation would depend on student need(s). Two respondents (less than 1%) indicated they would use the same accommodations provided to students with learning disabilities, specific language impairments or attention deficit hyperactivity disorder. One respondent revealed that special education (rather than SLPs) develops accommodations and another respondent said no accommodations are needed for students with a concussion. The survey also contained two yes/no items about promoting education and awareness on concussion. Few respondents (4.9%; n ¼ 11/223) have disseminated information regarding concussion, symptoms and what to expect from the injury to coaches, teachers, parents and students; and even fewer (0.9%; n ¼ 2/223) have provided an in-service to coaches, teachers or students regarding prevention of concussion. Eight survey questions aimed to determine respondents’ readiness for and opinions on providing services to students with concussion. Over half of the respondents (67%; n ¼ 146/ 218) felt uncertain that treatment for students with concussion is effective. Many respondents (68.5%; n ¼ 152/222) do not consider themselves to be the most knowledgeable resource among school personnel for information on concussion. When asked if they were aware of institutional (state; school district) documentation that defines what services should be provided by school SLPs, 52.9% (n ¼ 120/227) indicated no while another 13.2% (n ¼ 30/227) responded they were uncertain. When asked if it is an SLP’s responsibility to provide intervention to students with concussion in the school setting, a majority of respondents were uncertain (60.7%; n ¼ 136/ 224) and 30.4% (n ¼ 68/224) indicted yes. While 8.9% (n ¼ 20/224) indicated they did not feel it is an SLP’s responsibility to provide intervention to students with concussion in the school setting, 62.2% (n ¼ 140/225) of respondents believe it is within an SLP’s scope of practice to provide treatment to students with concussion in the school setting and 34.7% (n ¼ 78/225) were uncertain. A third of

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respondents (31.3%; n ¼ 71/227) thought that colleagues and school administrators believe that concussion intervention has education relevance. When asked if the school district has concussion management procedures, protocols and guidelines to assist SLPs working in the school, 54.1% (n ¼ 124/229) of respondents said no, while 41.9% (n ¼ 96/229) were uncertain. The final question in this section asked if respondents were confident in their ability to provide treatment to students with concussion. Only 21.8% (n ¼ 49/225) felt confident in their abilities, while 43.1% (n ¼ 97/225) were not confident and 35.1% (n ¼ 79/225) were uncertain.

Considering training related to concussion, only 21% of respondents indicated they received training in school coursework or continuing education and less than half (41%) of those respondents performed clinical practica with a client with concussion. Previous research has linked the lack of confidence and feelings of unpreparedness SLPs feel in delivering services to individuals with TBI to a lack of training [20, 21, 25]. The results of this survey suggest that these same challenges remain, particularly in the area of concussion, and may represent a barrier to services for children with brain injury in the schools.

Follow-up and monitoring

Knowledge of SLPs

Respondents were asked several questions regarding followup and/or monitoring procedures of students with concussion. Many respondents (70.4%; n ¼ 159/226) indicated that they do or would re-assess students at regular intervals if they were not impaired at initial evaluation following a concussion. The most commonly reported time frames for re-assessment were once a month (39.6%; n ¼ 57/144) or every 6 months (34.7%; n ¼ 50/144). Sixteen per cent (n ¼ 21/144) of respondents do or would re-assess students once a week, while 12% (n ¼ 16/ 144) re-assess students once a year. When asked if they routinely follow students after discharge, 61.3% (n ¼ 138/225) of respondents reported they do or would. The two most common intervals for follow-up were once a month (39.7%; n ¼ 50/126) and every 6 months (38.1%; n ¼ 48/126). The last question in this section asked when respondents typically terminate follow-up. The most frequently response was after 12 months (43%; n ¼ 73/168).

SLPs have a mix of accurate and inaccurate knowledge regarding concussion. For example, the majority of respondents accurately indicated that a concussion is a brain injury; however, 30% stated that a concussion can result in structural damage that is visible on CT or MRI scans. Hux et al. [23] found this to be a common misconception of SLPs as well. This suggests an insufficient understanding of the nature of pathology across brain injury severity or of the resolution of common clinical neuroimaging technology (i.e. CT and MRI are not well suited for diagnosing mild TBI and concussions [8, 29]). In addition, over 60% of respondents stated that children show better recovery from concussion than adults, while recent research indicates that children are actually more vulnerable than adults to the effects of diffuse damage following TBI [30–32]. There was also lack of knowledge and uncertainty in the respondents’ abilities to define words associated with concussion and TBI. For example, while 80% of respondents reported having received specific TBI training, over 70% of all respondents indicated they could not define the terms diffuse axonal injury and anterograde amnesia. There has been an increase in the number of SLPs receiving TBI training over the past two decades. Yet, this training does not appear to significantly impact respondents’ concussion knowledge. Responses were similar for individuals with and without TBI training. Why would TBI training not improve knowledge of concussion? One possibility is that general TBI training is weighted more towards moderate and severe TBI than concussion and mild traumatic brain injuries. Another possibility is that respondents’ training did not occur recently enough to include all of the new information on concussion that has come into the literature in the past 10 years. Indeed, there has been a surge in the amount of attention given to concussion recently and the research literature on concussion and best practices have changed radically over the past decade [14, 33]. This may also explain why training specific to concussion increased respondents’ concussion knowledge in only some areas.

Discussion Paediatric concussion is a growing public health issue. While most individuals with a mild brain injury like a concussion do not have long-term deficits, a smaller minority of individuals will present with more persistent cognitive communication disorders that can negatively impact academic and social success [11, 18, 19, 28]. The current study surveyed practicing school-based SLPs across the US to get a snapshot of concussion knowledge and practices. These findings serve as a baseline upon which changes in SLP training and knowledge and the standard of concussion care can be measured. While this study will not comment on the full set of results, below is a set of observations based on the current results and previous surveys work and some recommendations for future research and clinical practice. Increasing concussion training to improve knowledge Lack of concussion training In the present study, 80% of respondents reported receiving TBI training. This represents a significant increase in TBI training over the past two decades, as Hux et al. [23] reported that only half (52.2%) of respondents from their national survey in 1996 had specific TBI training. This increase is a positive trend and suggests that efforts to increase training have been successful; however, the current results also suggest that 20% of school SLPs still have little to no TBI training, despite the fact that brain injury services are part of the scope of practice.

Increasing course work and continuing education opportunities in concussion Although there have been numerous calls for increasing the graduate coursework and training in cognition and TBI [20, 21], doing so is challenging. As the field continues to grow, there are more and more demands on the graduate SLP training curriculum. In the authors’ experience, graduate level courses dedicated to TBI are rare and are most often offered as

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an elective enrolled overwhelmingly by students who want to work in adult neurogenics. Yet, TBI is most prevalent in paediatric populations (infants, 14–25 year olds) and nearly half of all practicing SLPs work in the schools. Students preparing for careers as school-based SLPs need course work and training in TBI and cognition. Increasing course offerings in normal cognitive processes and TBI as well as teaching graduate students headed to the schools about the importance of being ready to serve children with TBI and other cognitivebased language and communication deficits would improve clinician confidence and the quality of service to clients with TBI. Training in TBI should be expanded to include coverage of mTBI and concussion. National brain injury statistics suggest that mTBI and concussion make up the majority of brain injury cases annually. Continuing education opportunities, both nationally and through state and local associations, are critical for providing school-based SLPs with timely information on best practices for students with concussion. Finally, one needs to re-examine the content of the TBI instruction. While there is an increase in the number of clinicians receiving TBI training, their knowledge of key concepts and terminology was surprisingly low in some areas. Improving stakeholder communication will lead to better concussion management Gaps in communication The findings suggest a persistent lack of communication between SLPs and other stakeholders (e.g. teachers, coaches, administrators, parents). Only 12% of respondents indicated that they were notified when a student sustains a concussion and only 5% of respondents have communicated with stakeholders about concussion. This result is similar to a survey of 78 Illinois school SLPs where only 6% of respondents were informed when a student experienced a sports-related head injury and less than 2% communicated with stakeholders about concussion [26]. Moreover, of those respondents who do receive referrals, the overwhelming majority (95%) receives only 1–5 referrals per year. Given the statistics on the incidence of concussion, one might expect SLPs to be notified of more students sustaining concussion. One could ask the question, however, is it really necessary for the school-based SLP to be notified of every concussion? Particularly considering that the overwhelming majority of students will not require any assessment or intervention. This is a reasonable question. It is the authors’ opinion that students would be well served if someone at the school were made aware of this event as it has the potential to affect academic and social performance at school, either immediately or over a longer time period. This study makes the case for this person being the school SLP, particularly when the district does not have a staff neuropsychologist. This notification should not automatically trigger an assessment, but would serve as an opportunity to communicate to teachers and parents about what signs and symptoms to look for and an obvious contact person should the student not recover in a timely manner and a contact person who would play a critical role in the management of the student.

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While it is difficult to know the exact dynamics that account for these gaps in communication, it is speculated that there is a contribution from SLPs’ confidence in their roles and their ability to serve students with concussion. That is, while Duff [18] and Salvatore and Fjordak [19] argue that SLPs are well suited to provide these services in the schools, the majority of clinicians in this study expressed a lack of confidence. Almost 70% of respondents in the current study do not consider themselves to be the most knowledgeable resource among school personnel for information on concussion and only 21% felt confident in their abilities. Given this context, it is perhaps not surprising that, of the 27 respondents that indicated a head injury team in their district, only 30% of SLPs were part of the team. Thus, a real challenge in improving stakeholder communication and getting teachers and other school personnel to recognize our role in serving children with brain injury is for SLPs to also recognize and embrace this role. Creating and maintaining open channels of communication to increase identification and improve management of concussion is an important step in this direction. Opportunities for engagement In our scope of practice, one is charged with providing a number of services including collaboration, education, prevention and advocacy [17]. Even for SLPs without extensive training or experience in brain injury, there are ways to create opportunities for dialogue with other stakeholders. Start a campaign. Get teachers, coaches, school administrators and students learning about concussion by launching a prevention awareness campaign. Around the world March is recognized as brain injury awareness month. There are a number of websites that provide concussion information and brain injury awareness campaigns (e.g. www.cdc.gov/concussion/ headsup/physicians_tool_kit.html; www.biausa.org/braininjury-awareness-month.htm) that can be co-ordinated with international and national organizations (e.g. International Brain Injury Association; Brain Injury Association of America; Safe Kids Worldwide) and events (e.g. Brain Injury Awareness Week; Playground Safety Week (see Duff [18] for more information). Join or create a brain injury team. A team approach to identifying and providing services to children with concussion that promotes cognitive, communicative, academic and social success is ideal. Participating on brain injury teams allows SLPs to increase their own concussion knowledge and to educate other school personnel on how brain injury affects learning and the SLP scope of practice [34]. As a starting point, SLPs can begin by asking to sit in on brain injury team meetings, get to know other members of the team and/or ask for the brain injury team’s assistance in an awareness/prevention campaign. Developing better tools and strategies for better concussion management Need for more sensitive assessment tools Intimately tied to the ability to identify students with concussion is access to assessment tools that are sufficiently sensitive to detect the cognitive-communication deficits typical of individuals with brain injury. Results from this

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study suggest that SLPs are focusing their assessment time on basic language ability (expressive and receptive) rather than on cognitive-communication ability. Indeed, only 10% of respondents included memory in the areas of assessment; and problem-solving, executive function, auditory processing and attention were listed by less than 4%. Many of the formal assessments listed by respondents are not appropriate for paediatric TBI. For example, the most common assessment tool listed was the Clinical Evaluation of Language Fundamentals (CELF), with nearly 20% of SLPs in this study reporting its use. However, the CELF is insensitive to the detection of cognitive impairments that would impact communication ability. In a study examining the ability of the CELF-3 to detect the type of cognitive-communication deficits typical following brain injury, Turkstra [35] found that, while the CELF-3 is able to identify individuals with previous diagnoses of language impairment, it does not detect individuals with verbal information processing impairments or identify patterns of strengths and weaknesses. It is possible that a lack of knowledge about cognitive-communication disorders underlies this choice of assessment tool, but it is also the case that there are few formal assessment tools in the area of paediatric TBI. There are tools, however, recommended for their specificity and sensitivity in detecting deficits in the paediatric TBI population [36]. For example, the Woodcock Johnson Tests of Psycholinguistic Abilities was standardized on over 8000 healthy individuals ranging in age from 2–90. While this test does not provide norms for individuals with TBI, it can be useful for identifying deficits after TBI, as it measures intellectual activity and academic achievement [35]. Also, the Behaviour Rating Inventory of Executive Function (BRIEF) is a questionnaire for parents and teachers to complete based on a student’s behaviour in home and school environments. This tool, standardized on males and females aged 5–18, assesses executive function and is designed for TBI, learning disabilities, attentional disorders, depression and other disorders. The Paediatric Test of Brain Injury is another test recently developed to measure deficits unique to TBI. Whether or not these measures will pick up the deficits associated with concussion is an important area for future research. Re-thinking the approach to brain injury management Brain injury has traditionally been viewed in the context of a medical model where most conditions are fully treated or ‘fixed’ (e.g. broken leg, appendectomy) over a short period of time (e.g. days or weeks) [34]. Yet, brain injuries can have life-long consequences, which shifts the service delivery from the medical setting to the community and the schools. However, Todis [37] reported that 60% of children with TBI do not receive school-based services because of the delayed effects of the injury and a failure of long-term monitoring following brain injury. Given this context, one needs to rethink the service delivery model for children with brain injuries in the schools. There is a need for ongoing, long-term monitoring following brain injury. In the present study, 70% of respondents do or would re-assess students at regular intervals if a child were not impaired at initial evaluation. Forty-three per

Brain Inj, 2015; 29(1): 64–77

cent of respondents indicated they would terminate follow-up after 12 months and 16% would terminate after 2 or more years. The authors would advocate for procedures that monitor students with a history of brain injury throughout their schooling. This approach has several important benefits. First, such a conservative approach would significantly increase chances of capturing the onset of delayed effects of injury. This approach would also communicate to parents and teachers that, even if the child’s functioning appears on track, the brain injury may interfere with normal development down the road. As part of the monitoring team, these stakeholders are well positioned to observe early changes in functioning and achievement that would trigger closer observation and a timely formal re-evaluation. Long-term monitoring and early detection of deficits will increase accurate diagnosis and more appropriate intervention (e.g. classroom accommodations, reduced risk of additional brain injuries). Indeed, failure to acknowledge the delayed onset of deficits from the brain injury has been linked to misdiagnosis [25]. Second, transitions (e.g. back to school, to a new classroom, to a new teacher, to a new home) can be challenging for children, but they are particularly so for children with brain injury, making them vulnerable to setbacks. For students with a concussion, a stepwise transition back to school and a full academic course load is recommended to ensure time for cognitive and physical rest [14]. SLPs can help the student with these transitions by problem-solving new strategies and helping design and implement new compensatory techniques and educate parents and teachers. Some in the field, however, might take exception to this approach, as the potential number of students to monitor could be staggering. Indeed, there are estimates suggesting that 16% of children sustain one or more brain injuries requiring medical attention by age 10 [38] and that 30–37% of high school and college age students have experienced at least one brain injury [39]. Furthermore, one must remember that the vast majority of students are thought to make full recoveries without intervention and that only a small sub-set of students will present with cognitive and somatic deficits after a few days. So, is long-term monitoring of students with a concussion realistic? How does the field and clinicians weigh the statistics above with the realities that children with brain injuries are an overlooked group in schools and many remain unidentified or even misidentified as having a disability other than TBI? These are the tough conversations there is a need to have. The authors completely agree that an annual, full SLP assessment and interdisciplinary team for every student with a concussion is unrealistic and, more importantly, unnecessary. Alternatively, having a school record of which students have a history of one or more concussions (or more severe brain injuries), educating school personnel about the signs and symptoms of concussion (cognitive and physical) and when students are most at risk for the delayed effects of brain injury (e.g. when the cognitive and social demands of school life increase, transitions to new schools) [40] and establishing a system of communication to alert interested parties that a student with a history of brain injury is having academic or social difficulties could lead to more accurate and timely identification of student needs and reduce negative outcomes (e.g. cognitive stall [41]) for

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students, even if they are a small minority. Furthermore, there is a need to recognize that the approach may change over time. The proposal here for student monitoring may prove to be overly aggressive or too conservative. Indeed, there remain a number of unanswered questions in the literature about how sex and number of concussions affect the brain and long-term academic and social success [42–45]. Whatever the best approach, it is hoped this work will begin a dialogue among clinicians and researchers. Caveats and limitations The responses of SLPs should be interpreted with caution for some questions. The wording of some questions (e.g. What formal assessments do you use to evaluate concussed students?) may require the assumption that all students with a concussion should be assessed or that the student is experiencing long-term consequences of the concussion. The same critique could be made of the treatment questions. The current study captures current knowledge and practices of school-based SLPs in the US and these results may or may not be an accurate reflection of knowledge and management of SLPs around the world. Future research examining concussion knowledge and training and the role of SLPs in concussion management, outside the US, is warranted.

Conclusion The topics of concussion management and the role of the SLP have garnered increased attention. There have been a number of advances in understanding of concussion and how best to assess and treat individuals who have sustained a concussion. However, there are still gaps in the knowledge base. These advances and gaps present a unique set of challenges and opportunities for those providing clinical or educational services to children at risk for or who have sustained a concussion. It also raises a set of fundamental questions about the role and obligations of SLPs in service delivery. It is hoped these data provide a starting point for conversations about how best to increase the knowledge base of SLPs and establish best practices for students who have sustained concussions and other forms of brain injury in the schools.

Declaration of interest The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

6. 7. 8. 9. 10.

11. 12.

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14.

15. 16.

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18. 19. 20. 21. 22.

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Appendix A. Background information (1) How long have you been a practicing speech-language pathologist (SLP)? ________ years (2) What is the highest degree you have earned? (e.g. BA, MS, PhD) ________ (3) What is your current employment setting? (check all that apply) ____ elementary school ____ middle school/junior high school ____ high school

(4) YES NO Do you work full-time in one school?

B. Concussion knowledge and terminology The statements below are generalizations about concussion and do not account for individual differences. For each statement, please indicate your strength of agreement or disagreement with each statement as a generalization. If you are uncertain or do not have enough information to provide an opinion about a given statement, mark ‘Uncertain’. SA, ¼ Strongly agree; A ¼ Agree; U ¼ Uncertain; D ¼ Disagree; SD ¼ Strongly disagree. 1. 2. 3. 4.

SA SA SA SA

A A A A

U U U U

D D D D

SD SD SD SD

5. 6. 7. 8. 9.

SA SA SA SA SA

A A A A A

U U U U U

D D D D D

SD SD SD SD SD

10. 11.

SA SA

A A

U U

D D

SD SD

12.

SA

A

U

D

SD

13.

SA

A

U

D

SD

Loss of consciousness is required for a diagnosis of concussion. A concussion is a brain injury. Children show better recovery from concussion than older individuals. The signs and symptoms of concussion can overlap with symptoms of other disorders such as depression, anxiety and attention-deficit disorder. Recovery from a concussion is complete when the individual is asymptomatic. Concussion makes an individual more vulnerable for a subsequent injury. Concussion can affect academic performance. Cognitive rest is important for recovery from a concussion. A standardized protocol or return to play guidelines is important for determining when a student returns to competitive play. Physical rest is important for recovery from a concussion. Individualized baseline neuropsychological testing for student athletes is part of concussion prevention and management. Concussed students are eligible for accommodations such as specialized instruction or other educational accommodations. Concussions result in structural damage that is visible on CT or MRI scans. (continued )

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14. 15. 16.

SA SA SA

A A A

U U U

D D D

SD SD SD

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Multiple concussions are required to observe long-term cognitive deficits. Concussions can occur in individual or group recreational sport or activity. A repeated concussion that occurs before the brain recovers from the first can slow recovery or increase the likelihood of having long-term problems.

17. Please state two or more frequently observed symptoms of a concussion. _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ _____________________________________________________________________________________________________________________ 18. Can you define the following terms? YES NO Second impact syndrome YES NO Lability YES NO Diffuse axonal injury YES NO Retrograde amnesia YES NO Post-traumatic amnesia YES NO Confabulation YES NO Glasgow Coma Scale YES NO Anterograde amnesia YES NO Executive Functioning YES NO Consciousness

_____________________________________________________________________________________

C. Referral (1) YES

NO Are you notified when students sustain a concussion at or away from school?

If YES, please answer questions 2, 3, and 4. If NO, please answer the following questions. YES NO Do you think you should be notified? YES NO Do you know who is notified? If YES, who is notified at your school? ________________________________

(2) How many referrals following concussion do you receive per year? ____ 1–5 referrals per year ____ 6–15 referrals per year ____ more than 15 referrals per year

(3) Who notifies you that a student has sustained a concussion? (check all that apply) ____ student ____ parent ____ teacher ____ coach/athletic trainer ____ school nurse ____ physician ____ other (please specify)____________________________________________

(4) Typically, how long after injury do you receive the referral? ____ within 24 hours of injury ____ within 1–7 days of injury ____ within 1–4 weeks of injury

____ within 1–3 months of injury ____ within 4–6 months of injury ____ more than 6 months after injury

D. Assessment (1) YES

NO Have you ever provided assessment for a student with a concussion?

If you have worked with a student with a concussion, please answer these questions based on your current practices. If you have not worked with a student with a concussion, please answer based on how you would approach assessment.

(2) What formal assessments do you use to evaluate concussed students?

_____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ (3) What informal measures/assessments do you use to evaluate concussed students?

__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ (4) Which areas do you most often assess in concussed students? (e.g. expressive language)

__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

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E. Management (1) YES

NO Have you ever provided treatment for a student with a concussion?

If you have worked with a student with a concussion, please answer these questions based on your current practices. If you have not worked with a student with a concussion, please answer based on how you would approach assessment.

(2) What areas do you most frequently target when treating concussed students?

__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ (3) How long do you typically treat concussed students? ____ less than a month ____ 1–3 months ____ 4–6 months

____ 7–9 months ____ 10–12 months ____ more than a year

(4) What classroom accommodations need to be made for some concussed students?

__________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ (5) YES NO Uncertain Do you feel that treatment for concussed students is effective? (6) YES NO Uncertain Do you consider yourself to be the most knowledgeable resource among school personnel for information on concussion? (7) YES NO Uncertain Have you ever provided an in-service to coaches, teachers or students regarding prevention of concussion? (8) YES NO Uncertain Do you give literature to students, family members, teachers and/or coaches regarding concussion, symptoms and what to expect with this injury? (9) YES NO Uncertain Are you aware of documentation at the state level that defines what services you should provide as a school SLP? (10) YES NO Uncertain Is it an SLP’s responsibility to provide intervention to concussed students in the school setting? (11) YES NO Uncertain Is it within an SLP’s scope of practice to provide treatment to concussed students in the school setting? (12) YES NO Uncertain Do you think your colleagues and school’s administrators believe that concussion intervention has educational relevance? (13) YES NO Uncertain Does your school district have concussion management procedures, protocols and guidelines to assist SLPs working in the schools? (14) YES NO Uncertain Do you feel confident in your ability to provide treatment to concussed students?

F. Follow-up and/or monitoring Please answer these questions based on your current practices. If you have never provided services to a concussed student, please answer based on how you would approach follow-up and monitoring.

(1) YES NO For students who have sustained a concussion and are not impaired at the time of a speech-language evaluation, do you re-assess these students at regular intervals? If YES, how often do you re-assess the student? __________ once a week __________ once a month __________ every 6 months __________ once a year

(2) YES

NO Do you routinely follow students after discharge?

If YES, what is your typical interval? __________ once a week __________ once a month __________ every 6 months __________ once a year

(3) When do you typically terminate follow-up? ____ within 1 month ____ within 3 months ____ after 6 months

____ after 12 months ____ after 18 months ____ after 2 or more years

G. Speech-language pathologist education and experiences (1) YES

NO Have you had specific training related to concussion?

If NO, move on to question 2.

DOI: 10.3109/02699052.2014.965747

Paediatric concussion

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If YES, did the training occur: (check all that apply) ________as part of your undergraduate or graduate education (go to A) ________through in-services, workshops, conferences, seminars, etc. (go to B)

A. YES NO Did you perform clinical practica with concussed individuals? B. Which categories best describe where you received your training: ________poster sessions, technical sessions, mini-seminars or short in-services ________half-day or full day conferences such as workshops or seminars ________university courses taken after completion of your degree ________self-taught (books, websites, peer reviewed journal articles)

(2) YES

NO Have you had specific training related to TBI?

If NO, move on to question 3. If YES, did the training occur: (check all that apply) ________as part of your undergraduate or graduate education (go to A) ________through in-services, workshops, conferences, seminars, etc. (go to B)

(A) YES NO Did you perform clinical practice with TBI patients? (B) Which categories best describe where you received your training: ________poster sessions, technical sessions, mini-seminars or short in-services ________half-day or full day conferences such as workshops or seminars ________university courses taken after completion of your degree ________self-taught (books, websites, peer reviewed journal articles)

(3) YES (4) YES

NO Have you ever provided services in a medically-based setting? NO Does the school or school district in which you work have a head injury team?

YES NO If YES, are you a part of this team? Thank you for participating in this study. Please return this survey within the next 2 weeks in the enclosed pre-addressed stamped envelope. If there is anything else you would like to say about your experience with concussion or concussed students, please use the back of this page. If you are interested in receiving more information about concussion, please provide your contact information.

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