Children with a concussion may no longer have to sit quietly in a dark room for days. New research suggests that prolonged absence from school and other activities may hinder recovery from a concussion. Returning to school earlier than previously recommended may be associated with lower symptom burden, leading to a faster recovery, according to an article published online in JAMA Network Open.  

The analysis is based on data from the prospective study Predicting Persistent Postconcussion Problems in Pediatrics (5P) study, which was conducted between August 2013 and June 2015 in 9 pediatric emergency departments in Canada. All participants (n=3063) were aged 5 to 18 years and presented at the ED within 48 hours of sustaining a concussion. None of the children had a Glasgow Coma Score of 13 or less, had abnormal brain computed tomography or magnetic resonance imaging findings, or required hospital admission for multisystemic injury or neurosurgical intervention.

The present study analyzed data from a cohort of 1630 participants with documentation of a specific return to school date, who did not have a prolonged absence (ie, >20 days), and did not sustain the injury during a period of school closure including holiday and summer breaks.  The study was designed to examine the association between return to school timing and symptom burden at 14 days postinjury.

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The primary outcome was symptom burden at 14 days postinjury as assessed using the Postconcussion Symptom Inventory (PSCI). The children were categorized into 3 age groups (5-7, 8-12, and 13-18 years) and were given different versions of the PCSI that contained 13, 17, and 20 items, respectively, and with each item rated on scales of 0 to 2, 0 to 2, and 0 to 6, respectively. The possible PCSI score ranges for these versions were 0 to 26, 0 to 34, and 0 to 120, respectively, the study authors explained.

Early Return to School Linked to Improved Outcomes

Early return to school (missing 0-2 days) was documented in 875 children (53.7%). The mean number of school days missed across all groups increased with age (5-7 years, 2.61 [5.2]; 8-12 years, 3.26 [4.9]; 13-18 years, 4.71 [6.1]).

Early return to school was associated with a lower symptom burden 14 days after experiencing a concussion in the 8 to 12 and 13 to 18 age groups compared with late return to school (missing 3 or more days; Table). The association between early return to school and lower symptom burden was strongest among those with higher initial symptom levels among children aged 8 to 18 years.

Table. Effect of Early vs Late Return to School on Symptoms at Day 14 After Concussion by Age Group

Age GroupEarly vs Late RTS on PCSI Score, SMD (95% CI)P value
5-7 y-0.709 (-1.430 to 0.013).05
8-12 y-1.668 (-2.339 to -0.997)<.001
13-18 y-3.145 (-5.247 to -1.043).003

CSI, Post-Concussion Symptom Inventory; RTS, return to school; SMD, standardized mean difference.

Source: Vaughan et al.

The association between earlier return to school and lower symptom burden may be associated with the benefits of socialization, reduced stress associated with not missing too much school, adhering to a normal sleep-wake schedule, and returning to physical activity, the researchers noted. Findings also indicated that prolonged activity restriction increases the risk for mood disorders like depression and anxiety. Additionally, absence from school may increase screen time, which may hinder recovery.

“Differences in injury, symptoms, and activity tolerance should be considered when providing individualized clinical guidance,” the study authors concluded. “These findings support current guidelines indicating that early [return to school] can benefit physical and mental health. We recommend early [return to school] with accommodations as required.”


Vaughan CG, Ledoux A, Sady MD, et al. Association between early return to school following acute concussion and symptom burden at 2 weeks postinjury. JAMA Netw Open. 2023;6(1):e2251839. doi:10.1001/jamanetworkopen.2022.51839