Sorry in advance for venting as I know some folks have it worse. But I want to share my story about my 13 year old daughter "M" as I am broken hearted to see her suffer and I would like to get input on return-to-school approaches.

In September, M got hit in the head with a basketball in gym class. The ball was stuck in the ceiling and then came loose and hit her in the forehead from a great height. I took her to the emergency room, they did a scan which came back OK, she appeared to have no obvious neurological issues. Emergency room doctor as well as her regular doctor said "OK to return to school with cognitive breaks". Since then, M has headaches that never go away. Headaches vary from 1) "I can ignore it" to 2) "Hurts" to 3) "Really Hurts" depending on how much sustained schoolwork/classroom activity she does. When her headache is at level 1 or 2 you would almost not know she has a concussion, she functions well and is her bright and expressive self. But at 3 she has difficulty concentrating and needs to lie down and I cry about the pieces of her life that are passing her by.

In September and early October she was trying to do a full day in school with rest in the nurse's office as needed, but her headaches were at level 3 most days. It was difficult to get through all her homework and she was acting a bit scattered. She took two weeks off in October and towards the end her headaches were almost 0. After the two weeks, she went back to trying a full day with ad hoc breaks, and within a few days her headaches were right back up to 3. Her regular doctor put her on a half day starting beginning of November. The school put together a schedule of 4 out of 9 periods which focused on core subjects and alternated classroom time with rest periods in the nurse's office. On this schedule M did better. Her headaches were at 1 most of the time with occasional 2's. She could get through her homework fine but still acted scattered sometimes.

M saw Neurologist 1 in mid-Nov. Neuro1 said to aim for partial activity; no activity is not good, and too much activity is not good. He put all the burden on the school to figure out how to help my daughter through this.

In early December the school nurse and I compared notes on my M's headaches and she seemed to be doing relatively OK, so we increased her schedule to 5.5 periods out of 9.

M saw Neuro1 again in mid December but I was really put off by him. He rambled, asked M bizarre questions and was highly critical of the school without providing much in the way of specific instructions. I decided to seek another neuro.

I took M to see Neuro2 a week later. Neuro2 is part of the NYU-Langone concussion program in NYC. I liked Neuro2. She listened attentively, took detailed notes, and gave M a thorough neurological exam that tested her memory and thinking skills which came back good. Neuro2 OK'd the 5.5/9 schedule and refered my daughter to Neuropsychology. I told Neuro2 that I was looking for guidance on how adjust my M's schedule over time, but Neuro2 said that Neuropsych are the ones who coordinate with the school. Does that sound right to you?

Since the 5.5/9 schedule M's headaches are at 2 most of the time with some 1's and 3's. She acts less scattered and I've helped her be more disciplined about her homework. Throughout, M is in good spirits and doesn't complain and is her usual sunny self for the most part.

I see two possible approaches:
1) Give M partial school activity to the level she can handle.
2) Reduce school activity to 0 until symptoms go to 0, then increase very slowly, stopping if symptoms go above 0.

So far we are following #1. That was what Neuro1 recommended, and Neuro2 endorsed it. The partial schedule gives M a good chance of passing the school year.

But I wonder about #2. After reading other stories here, I feel she was truly blessed to have been able to bring her symptoms to 0 with two weeks off in October. Maybe we should be aiming to keep her symptoms at 0 and increase very slowly, backing off if her symptoms go above 0, for however long it takes. But that may cause her to repeat the year, Heaven forbid. That would be a big emotional blow to her.

Please let me know what you think.

westerner,

Welcome to NeuroTalk. Sorry to hear about your daughter.

I think #1 is OK but your focus with her should be to help her to learn when she is just starting to overload. Head aches don't likely start increasing any sooner than other signs of overload start to manifest. She may need to reread a line of text or not understand what was said by the teacher, even momentarily. These are signs she is starting to overload. She may need to wear ear plugs to reduce sounds. She should probably sit at the front of the class so the teacher's voice is clearer and not as mixed with the other noises in the classroom. She should minimize time spent in the halls or any classrooms where there are multiple voices talking at the same time.

A NeuroPsych who understands concussions and classroom struggles may be able to help her with these issues. (I would not get my hopes up, though)

Has she had her neck evaluated ? Is it stiff at all/ Often, concussions are made worse by subtle neck injuries. It will take a very skilled professional to help her with a subtle neck injury. Head aches can often be made worse by these neck injuries.

As much as she wants to keep up with her peers, she will likely be better off needing to repeat a class after getting an incomplete than have a low grade on her transcript. I dropped more than half of a Grade Point my sophomore year but recovered my junior year. That made a substantial difference in my graduating class ranking.

She needs to understand that her struggles have no reflection on her academically. They are due to her head injury. She is fortunate to live in a time where schools have a better understanding of the struggles students can have after a concussion. My teachers gave me no grace back in 1970/71 despite the doctor's comments to the school.

It boggles my mind that students have 9 classes in a day. That just makes my head spin. I never took more than 5 academic classes plus PE and a non-academic elective. I agree with her need to simplify her class load.

Please, if you can, help her learn how to moderate her exposure level. It will be a very important skill. She needs to have her memorized ways to excuse herself such as, "I am starting to feel overloaded. I need to excuse myself and take a break." Her friends need to know to support her in this. It means she also needs to take a break from her friends and their talking.

If she can do this, she should be able to keep up with some of her schooling.

My best to you both.

Hi Mark, thanks for the reply.

M is getting better at managing her condition. She is doing a better job checking herself periodically for when to take a break. I'll follow up with her regarding your suggestion of taking a break when her concentration in class is wavering, and not necessarily waiting for a headache. Thankfully, she is not sensitive to light or sounds. Thankfully, she has no problem socializing with multiple people. I attribute that to the fact that she has always been very social, and hanging out with her friends for a while does not seem to tax her, and helps her morale.

She does not have any pain or stiffness in her neck, thankfully.

I agree that pushing her academically at the expense of grades is not the right approach. So far, the reduced school schedule is taking all her energy but she is getting good grades. Each evening, I sit with her and we plan out the homework she has to do that evening and in the coming days. I check in with her from time to time to keep her focused. She spends her time only on homework and resting. No video games or recreational reading. She takes some time off on weekends for extra sleep and hanging out with friends for a while. Thankfully, her sleep pattern has been normal.

Her morale remains good, thankfully.

One open question I have is how to get her some exercise and in what form. She is scheduled for PT, maybe they will have some ideas.

Overall I would say she is coping and we pray this gets better over time.

Glad to her is progressing.

I would not worry about getting her exercising. Some simple walks should be enough. If they cause a head ache, reduce the distance, pace and such the next time.

I am concerned about the amount of time she spends doing homework if you need to keep her focused. She may need to take breaks then return to the task rather than be pushed. I could only stay focused on a task/activity for about 15 minutes then needed a break or changed to a different activity/task.

What is the PT for if she does not have a sore/stiff neck ? btw, That does not mean she has not suffered a subtle neck injury/strain.

The important concept is to reduce the peak activity levels. Rest between high activity levels is not the same as reducing the peak levels. Extra sleep because she has been working hard all week may work for a healthy person but the injured brain only heals when peak efforts are lowered and avoided. The key is moderating the effort level.

Have you read the vitamins and supplements sticky at the top ? Post 101 on Nov 8, 2014 has the updated information.

My best to you both.

Update:
Mark, in answer to your PT question, the PT was to rule out vestibular issues and they have given her balance and walking exercises to do every day. She went a few times but I will probably cut it back now and let her do the exercises at home.

M's neuropsychology results are in. The testing showed a very high IQ but low processing speed. The agrees with my observation that she is quite slow on written English assignments. But Math speed is OK.

I liked the neuropsychologist. I feel she understood my daughter's case and made good recommendations. She spent an hour on the phone with her school and me discussing the return-to-learn plan. Here are the details:

-Cut school load so that headaches stay at "light" pain level or below. Currently her headaches are a mix of light and moderate.
-M's class load to stay at 4 periods per day out of 9, alternating class times with rest periods in the nurses office.
-Take 5-10 min breaks between classes when she has classes back to back.
-Cut homework to 30 mins a night. Previously she was doing 2.5 hrs to try and keep up.
-Tests to be limited to brief quizzes and she will be graded on a pass/fail basis. Previously she was taking regular tests in those classes she was attending.
-Regular logging of headache level and revaluate in 2 weeks.

Her processing speed issues may be due to:
-Perfectionism. The neuropsych noticed in testing that she had a tendency to hesitate on an answer because she wasn't sure it was right, and to go back and forth on it for a while. I've noticed the same thing in homework. The neuropsych recommended that she see a therapist for this.
-Side effect of the topimate she's taking (50mg, a light dose) which can make the brain foggy.
-Other unknown factor due to the injury.
I am thinking of getting her a special ed. teacher to work specifically on the processing speed issue for 90 mins per week or so and flush out what is really going on. Maybe she can be re-educated on this. It will probably need a really good special-ed teacher who can adapt their techniques to her particular case as she does not have a learning disability, she has a brain injury.

Any comments are welcome.

I like that the NP has set the 30 minute limit on homework. Her recover is far more important than her keeping up with her class. The slowed processing can be tested in ways that eliminate the perfectionism issue. Something that is evident but the NP did not mention is that a high IQ with low processing and other cognitive functions is usually a strong indicator of organic (injury) as a cause. But you know that.

Ever since my first injury at 10 years old, my verbal processing has been lacking even though my math processing has always been good to excellent. She may need her verbal processing functions looked at by a specialist.

I suggest you check with http://nacd.org/ to see if they can help. They have a testing program that is good at identifying issues. Then they tailor a program to the student's needs.

A question for you to answer for yourself. Would you rather she push and graduate on time but frustrated and floundering ? Or take 14 years for finish and graduate with a solid understanding of how to be a successful student ?

I never learned how to work with my dysfunctions and struggled in college. I had already completed most of my college prep high school courses by the time I had my serious academic meltdown in high school so I skated through my junior and senior year and graduated with honors. I wish I had a better understanding of how to be a successful student.

Hopefully, you will be able to find the help she needs to understand how to learn with slowed processing. It can make it difficult to memorize information.

More later.

My best to you.