Delayed Return to School After Concussion in Adolescence Hampers Recovery

Return to school within 2 days after concussion was associated with lower symptom burden at 14 days postinjury compared with a later return.

After sustaining a concussion in childhood or adolescence, a prolonged absence from school or other life activities may hamper recovery, according to study findings published in JAMA Network Open.

Most guidelines recommend for youth to undergo physical and cognitive rest for 24-48 hours after concussion followed by a gradual return to school. However, there remains little empirical evidence supporting these guidelines.

To evaluate the effects of return to school timing after concussion in adolescence, data for this analysis were sourced from the Predicting Persistent Postconcussion Problems in Pediatrics (5P) study, which was conducted between 2013 and 2019 at 9 emergency departments (EDs) in Canada. For this study, postconcussion symptom burden at 14 days were evaluated on the basis of return to school delay.

The study population included 282 children aged 5-7 years, 700 adolescents aged 8-12 years, and 647 youth aged 13-18 years. The groups comprised 32.4%-45.4% girls, 65.7%-88.0% had never had a concussion, the average time between injury and triage was 6.36-11.00 hours, 49.1%-80.4% were injured during sport or recreation, and Post-Concussion Symptom Inventory (PCSI) score was 6.87-34.82 points at the ED.

These findings suggest prolonged absence from school after a concussion is associated with a greater symptom burden and may be detrimental to recovery,

Excluding weekends, the average number of school days missed was 3.74 (standard deviation [SD], 5.5) days. In general, the oldest youth missed more days (mean, 4.71 days) than the youngest children (mean, 2.61 days). More than half of the children were early returners, missing 2 or fewer days (53.7%) and the remaining children were late returners, missing 3 or more days (46.3%).

In a propensity score matching analysis, those that returned to school later had poorer PCSI outcomes than those who returned early among the:

  • youngest children (standardized mean difference [SMD], -0.709 points; P =.05),
  • adolescents (SMD, -1.668 points; P <.001), and
  • oldest youth (SMD, -3.145 points; P =.003).

Stratified by initial PCSI score, children who returned to school later had poorer PCSI outcomes compared with early returners for:

  • children aged 5-7 years who were in the 10th percentile for initial PCSI score (SMD, -1.371 points; P =.03),
  • adolescents aged 8-12 years who were in the 75th (SMD, -2.036 points; P =.001) or 90th (SMD, -3.055 points; P <.001) percentiles initially, and
  • youth aged 13-18 years who were in the 90th percentile initially (SMD, -4.475 points; P =.02).

The major limitation of this study was the observational design, in which return to school timing was not randomized.

“These findings suggest prolonged absence from school after a concussion is associated with a greater symptom burden and may be detrimental to recovery,” the researchers noted. Children and adolescents who did not miss more than 2 days of school after concussion had lower symptom burden 14 days after the concussive event compared with those who delayed return to normal routines. These findings conflict with current guideline recommendations and warrant formal testing in a randomized trial.

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.


Vaughan CG, Ledoux A-A, Sady MD, et al. Association between early return to school following acute concussion and symptom burden at 2 weeks postinjury. JAMA Netw Open. Published online January 3, 2023. doi:10.1001/jamanetworkopen.2022.51839