The Other 60 Percent

A teen’s death prompts schools to improve concussion management

It was a hot August afternoon and football practice was just getting underway at Cherokee Trail High School in Aurora. Amid the gruff calls of assistant coaches and the smack of colliding shoulder pads came Coach Monte Thelen’s matter-of-fact voice at the end of each play, “Stay up, stay up, stay up!”

Football players at Cherokee Trail High School take part in a “thud” practice as an assistant coach looks on.

It was a half-pads “thud” practice and he wanted players to stay on their feet.

“We’re trying to limit the number of times players hit the ground with each other,” said Thelen. “We didn’t do that 10 years ago. I’m not even certain we did that eight years ago.”

This kind of safeguard is just one of many measures that has been employed over the last several years to help prevent an invisible and potentially life-threatening injury: concussions. In the Cherry Creek school district, where Cherokee Trail is located, the issue resonates with particular intensity because it is where Jake Snakenberg, a Grandview High School freshman, was playing football in 2004 when he took a routine hit and died of “Second Impact Syndrome” the next day.

Along with increasing awareness about concussions in the NFL and at the collegiate level, the 14-year-old’s death helped change the way youth concussions are handled in Colorado, giving rise to the Jake Snakenberg Youth Concussion Act, which took effect Jan 1, 2012.

The death of an athlete may be the most frightening consequence of concussions, but memory problems, concentration problems and other temporary cognitive deficits are more common outcomes. So while coaches and other advocates of good concussion management certainly want to prevent lethal “second hits,” they also want to ensure that concussed students have an efficient recovery so they can function in the classroom.

“It’s not just about return to play. It’s not just about sports,” said Karen McAvoy, director of the four-year-old Center for Concussion at Rocky Mountain Hospital for Children “You cannot return to play until you have 100 percent returned to learn.”

While experts agree that “Jake’s Law” has improved concussion management practices, they say that the state’s school districts and even its doctors do not always approach concussion management in a uniform way.

In Colorado, there is no statewide database on the number of youth concussions, sports-related or otherwise. However, national studies suggest that high school athletes sustain an estimated 136,000-300,000 concussions per year and the numbers have steadily increased. A 2011 study in the American Journal of Sports Medicine found that concussion rates in high school athletics increased by 16 percent annually from the 1997-1998 school year to the 2007-2008 year. The same study found that the most concussions occurred in football, followed by girls soccer.

Concussion resources

Impact of Jake’s Law

Jake’s Law, which applies to students 11-18 in school, club or recreational sports, requires that students suspected of sustaining a concussion be removed immediately from practice or games. In addition, students must be cleared by a doctor or other health care provider before returning to play. Finally, the law requires coaches to take annual trainings on the signs of concussion.

McAvoy said the legislation also helped emphasize the medical side of the concussion equation. Prior to the legislation, families were under no legal obligation to get kids suspected of sustaining concussions during sports checked by a doctor, and some chose not to, she said. With its return-to-play medical clearance provision, the law changed that.

“Through all of this the thread that you see is the culture change,” said McAvoy, who was a school psychologist at Grandview High School when Snakenberg died.

McAvoy said districts like Cherry Creek, Jeffco and Dougco have been at the forefront when it comes to developing effective concussion management programs.

Dr. Danny Mistry, chair of the Concussion Task Force in Grand Junction, said that despite a dramatic increase in awareness because of Snakenberg’s death and his namesake law, youth concussion management practices vary widely around Colorado. Although there are exceptions, he said, the east side of the state is generally ahead of the west side.

“It varies because of resources and education,” said Mistry, who practices at Western Orthopedics and Sports Medicine in Grand Junction, and who is a primary care team physician for Colorado Mesa University and the Colorado Rockies, as well as a team physician for USA Swimming.

In communities where concussion management is lagging, it may be due to both health care providers and the school system.  For example, Mistry said, some doctors may not see many youth athletes and may not be aware of the latest protocol for concussion management. In addition, school districts often can’t afford widespread staff training on concussions.

Like others experts, Mistry and McAvoy emphasize that student concussions must be managed by a team including athletic staff, parents, health care providers and teachers, who can often provide critical feedback about how a concussed student is functioning in the classroom.

Mistry said he hopes the National Institutes of Health or state departments of education will eventually set aside money to educate schools on concussion management.

“We’re in the midst of an epidemic and we have to stem the tide,” he said.

Tools of the trade

Talk to high school coaches and athletic directors around the state and you’ll hear about a variety of tools in place for concussion prevention, identification and management. Often, they’ll note that changes were underway even before Jake’s Law took effect — they saw the direction the pendulum was swinging.

That swing may have started in 2009, when Washington passed the first in a flurry of state statutes on the issue, the Zackery Lystedt Youth Concussion Bill. Today, the District of Columbia and every state except Mississippi have some sort of youth concussion law.

In Colorado, concussion prevention and education efforts include switching to lower-contact drills, reducing the weekly number of full-contact drills, experimenting with protective equipment such as the “Guardian Caps” that fit over football helmets, giving coaches pocket-sized cards listing concussion symptoms and having players and their parents read and sign concussion information sheets.

The free REAP Project booklet from the Rocky Mountain Hospital for Children is used widely in Colorado. It has also been used in New York and Florida.

Many school districts also use a highly-regarded concussion management protocol written by McAvoy called REAP, which stands for Reduce, Educate, Accommodate, Pace. Contained in a colorful 11-page booklet available for free from Rocky Mountain Hospital for Children, the protocol emphasizes the team approach, the careful monitoring of physical, emotional and cognitive symptoms, and a graduated “return-to-play” that allows student athletes to ramp up physical activity over the course of several days.

As recommended in REAP, districts have increasingly addressed cognitive symptoms of concussions, such as mental fatigue and difficulty concentrating, by making accommodations in the classroom such as reduced note-taking or extra time on tests.

Mark Kanagy, assistant principal of Windsor High School and athletic director in Weld RE-4 School District, said this is true in his district. In some cases, the district has put in place a temporary 504 plan, which are normally used to accommodate students with disabilities, for a concussed student.

Some Colorado districts also use a computer-based test called ImPACT, which measure students’ neurocognitive function at a baseline level as sports seasons begin, and can be administered after a suspected concussion to help determine whether new deficits exist.

While experts caution that ImPACT tests aren’t foolproof, they say they can be one piece of the puzzle in determining whether students are affected by concussion. The test is used at about 100 Colorado middle and high schools, according to company officials.

Paul Cain, athletic director for Mesa County District 51, said his district pays about $1,000 a year to use ImPACT for students in football, soccer, lacrosse, basketball, baseball, softball, diving, and cheerleading, as well as for students in other sports whose parents have requested it.

Kanagy, assistant principal of Windsor High School and athletic director in Weld RE-4 School District, said ImPACT “makes things more quantifiable…It helps take some of the guesswork out of it.”

He said a student might feel fine and have no headaches or other symptoms after a concussion, but if the post-injury ImPACT test doesn’t align with the baseline test, it can indicate something is still wrong.

Still, not everyone thinks ImPACT is an ideal tool. They say that students packed in a computer lab taking the test may not earn reliable baseline scores because they are distracted or deliberately performing poorly. In addition, not all doctors know how to interpret the test.

McAvoy said most school districts never use ImPACT because of its cost. “And that’s okay,” he said. “ImPACT is not necessarily where I would put limited resources.”

Trickle down effect

As standards for concussion education and management among youth athletes have risen, advocates say non-sports concussions in youth are starting to get more notice as well. Those concussions may result from a car accident, a fall or a bicycle crash outside of school, which means school staff don’t always know about them right away, if at all.

The REAP Project booklet is dedicated to Jake Snakenberg, who died of “Second Impact Syndrome” in 2004.

“Our biggest issue is getting non-athletic concussions communicated to our schools,” said Cain. “As a community that’s the next thing we need to work on.”

It’s not unusual for non-athletic concussions to outnumber sports-related ones. During the 2011-12 school year, about 60 percent of 200 student concussions in District 51 were not sports related, said Mistry. At Cherokee Trail High School, there were 25 non-athletic concussions last year compared to 15 sports-related.

“Really it comes down to the responsibility of the parent, the responsibility of the child,” said Steve Carpenter, athletic director at Cherokee Trail.

While some families inform the school nurse about out-of-school head injuries and, in Cherry Creek district staff receive training on recognizing non-athletic concussions, Carpenter said, “Those are tricky ones.”

McAvoy said while Jake’s Law exclusively addresses sports concussions in 11-18 year olds, concussion guidelines she co-wrote for the Colorado Department of Education, also address concussions sustained outside of sports and in students under 11.

Still, since parents aren’t required to seek medical advice for non-athletic concussions, it can be hard for school staff to know how to proceed, she said.

“When does a school feel comfortable releasing them back to recess, physical education and those kinds of things?”

raising the curtain

Aurora high school students started rehearsing a musical about an earlier time — and discovered ‘harsh truths’ about today

Ebony Nash, left, sings during a rehearsal of Ragtime at Hinkley High School. (Photo by Yesenia Robles, Chalkbeat)

Nine weeks ago, more than 50 theater and choir students at Aurora’s Hinkley High School came together to begin work on a musical set in turn-of-the-20th-century New York.

At first, the kids did what high school students often do — cluster into familiar cliques, or self-segregate by race. Then the students started immersing themselves in the material.

The musical, “Ragtime,” intertwines the stories of a white family, a Jewish immigrant family and an African-American couple to spotlight differences and commonalities in the American experience.

At the urging of their teachers and directors, the Hinkley students began to use the plot and characters to examine their own actions, prejudice and biases. About 92 percent of Hinkley’s more than 2,100 students are students of color, the vast majority of them Latino.

The cliques and segregation slipped away. The production began taking shape.

“Ragtime” gets its Hinkley High School debut on Thursday and will be performed again on Friday and Saturday.

Chalkbeat sat down with a group of students involved in the production as they were in final preparations to learn about what their experience had taught them. The following is a portion of that conversation, slightly condensed and rearranged for clarity:

Janelle Douglas, a 17-year-old senior who portrays a friend of one of the story’s main characters, said the first time she saw and read through Ragtime, “it was intense.” She often cries as she rehearses her solo, sung during a funeral.

DOUGLAS: “I thought, this is powerful. This is overwhelming. This is amazing.”

Pamela Arzate, 17, plays the role of Evelyn Nesbit, a real model and actress who is incorporated into the fictional story and accused of being shallow.

ARZATE: “It’s very eye-opening because you look at it and it’s just a simple musical, but if you take a step back and go to the real world, it’s the exact same thing that’s going on today.”

Hodaly Sotelo, 17, plays the role of Mother, a woman whose attitudes toward her identity as a wife and woman evolve throughout the story.

SOTELO: “It reminds me of when I was younger and I was like, ‘Oh yeah, we’re over all that racism.’ But now, I look back and I think, what the heck? This stuff is still going on and we thought it was way over.”

Brianna Mauricio-Perez, 17, is one of two student directors.

MAURICIO-PEREZ: “It talks about all of the harsh truths that no one wants to talk about.”

DOUGLAS: “I think it’s safe to say it shows the true colors of our history.”

MAURICIO-PEREZ: “Even within our cast we did have to have a talk about how we were so separated because we were at the very beginning. Everyone was in their little groups and with their friends. You just want to keep to yourself.”

DOUGLAS: “It was literally ‘Ragtime.’”

MAURICIO-PEREZ: “We had a big talk with everybody. Things have gotten so much better. By the end of Act Two, we were all mixed up.”

Brenda Castellanos, 17, plays the role of Emma Goldman, drawn from a real-life political activist and anarchist.

CASTELLANOS: “Now that we’re closer, now that we’re all comfortable, we put in more effort.”

After nearly every rehearsal, teachers and directors give students a talk, urging them to immerse themselves in the feelings of their characters, relating to them if necessary through their parents, grandparents or ancestors who were immigrants, or through current events.

“What if you saw someone beaten, and bloodied and killed in front of you?” one director asked.

They also remind students of why the play should be impactful. “You have to figure out how for two-and-a-half hours you can give hope to that audience,” Marie Hayden, Hinkley’s choir director told students last week.

CASTELLANOS: “I think it it helps us. Every day, we get more into it and more into it until we actually believe it. You actually feel it — like how Janelle feels when she’s singing and she starts crying and makes everybody cry. We all feel connected.”

Students say they have different scenes that impact them the most, but they don’t hesitate to find how the scenes relate to their life despite the story being set in the first decade of the 1900s. Hayden’s class and the practice for the musical are safe places where they can discuss those parallels, they said.

Shavaun Mar, 16, is a junior who plays the main character of Coalhouse Walker Jr., a ragtime piano player who is the target of racial attacks and struggles with revenge and forgiveness.

MAR: “I feel like that is crucial that we give people those opportunities to talk because a lot of people have very valid things to say but they just don’t have a way to get it out.”

CASTELLANOS: “The shootings.”

ARZATE: “The racism. They help us discuss it because there’s so many things that are going on. Pretty much everyday there’s a tragedy going on. And so, in a way, we can use that sentiment, that emotion that we feel with the real world and convey it when we’re doing this show. We use those feelings and we try to think about it in that way. To display that emotion. To display it to everyone else. And not directly represent what’s going on today but just to give them that ‘aha’ moment, like ‘wow.’”

Ebony Nash, 17, plays the character of Sarah, an innocent girl who wants to help her boyfriend settle his problems.

NASH: “It just makes us want justice in real life because these things are still going on even though it’s not out there. It just makes us want justice for our community. This musical showed me that I need to become better within myself because I’m not perfect.”

SOTELO: “It opened my eyes a lot more for sure. This kind of just makes me realize the problems I have. It makes me realize yea, I’m having immigration issues with my father right now, but that also my friends, you know, they’re going through the same thing too. This DACA stuff or this coming out stuff. I became more accepting of what other people might be going through and how I can help.”

MAR: “The past few years, I have been in a bit of a shell. So putting myself in this situation and pushing myself to be this other person has really shown me what I’m capable of and it’s helping me break out of that shell and realize who I am as a person.”

NASH: “Basically, this is our getaway from real life because we get to come on stage and be somebody else. It also makes us want to put the story out right so people can understand. So people can feel what we want them to feel.”

CASTELLANOS: “That there’s hope after all this corruption that’s going on.”

DOUGLAS: “That even in your bad times you can still laugh, cry, dance.”

NASH: “What I want people to get from this is change. To learn how to change and learn how to forgive and learn how to come together as a community and just, like their worth.”

SOTELO: “And to be strong. To stand up for what’s right.”

ARZATE: “And it might sound weird, but I feel like they should feel a certain level of uncomfort because that means that they’re going to look at themselves while seeing the musical. Maybe they’ll go ‘I’m uncomfortable because I do that’ or ‘I have that prejudice’ or ‘I feel that certain way,’ so if they come out and they feel uncomfortable and then at the end they’re like, ‘Wow. There’s that hope for change.’ Hopefully that like…”

DOUGLAS: “… It inspires them to do better.”

ARZATE: “Like, you can do it.”

SOTELO: “It’s kind of like a water droplet. One small move can domino-effect to something bigger.”

 



Taking attendance

Want to make middle school admissions more fair? Stop looking at this measure, parents say

PHOTO: Monica Disare
Middle school students write their names down at a high school fair in Brooklyn.

Parents across New York City have pushed for changes in the way selective middle schools pick their students, saying the process is unfair.

Now, a group of Manhattan parents has come up with a novel solution: Stop looking at students’ attendance records.

The parent council in District 2 — where about 70 percent of middle schools admit students based on their academic records — points to research showing that students from low-income families are far more likely to miss school. Those children are at a distinct disadvantage in the competition for the district’s top middle school seats, the council argues, even though factors beyond the control of any fourth-grader — especially family homelessness — often account for poor attendance and tardiness.

“This outsized focus on attendance disproportionately impacts students who don’t have secure housing and may not have secure healthcare, and that is troubling to me,” said Eric Goldberg, a member of the community education council in District 2, which includes stretches of Lower Manhattan and the Upper East Side. “There are many factors that should not impact a student’s educational opportunities — and the way the system is set up, it does.”

Eighteen of the district’s 24 middle schools are “screened,” meaning they rank applicants based on factors including test scores, grades, and interviews. Of those, all but one school also considers how often students were late or absent in fourth grade, according to the parent council.

Most of the schools assign points to each factor they consider. Some give absences 10 times more weight than science or social studies grades, the council found, while others penalize students for even a single absence or instance of tardiness.

Disadvantaged students are especially likely to miss school.

A recent report by the city’s Independent Budget Office found that homeless students are more likely than other students to be chronically absent — typically defined as missing about 10 percent of the school year.

Schools with the highest chronic absenteeism are in communities in “deep poverty,” which have the highest rates of unemployment and family involvement with the child-welfare system, according to a 2014 report by the New School at the Center for New York City Affairs.

“We can use chronic absenteeism as a good guess of all the other things kids are dealing with,” said Nicole Mader, a senior research fellow at the New School and a co-author of the report. “If these middle schools are using absenteeism to weed kids out, that means they’re going to automatically weed out those kids who have the most barriers to academic success already.”

The attendance requirement can put pressure on any family, regardless of their financial status or housing situation.

Banghee Chi, a parent of two children in District 2, said she sometimes sent her younger daughter to school with a fever when she was in fourth grade rather than have her marked absent.

Her daughter would show up to class only to be sent to the school’s health clinic — which would call Chi to pick her up. Chi was thinking ahead to middle school, when a missed day of class could hurt her chances of getting into the most sought-after schools.

“It was something I was really conscious and aware of during my child’s fourth-grade year,” she said. “I think it’s unfair.”

The education council’s resolution, which will be put to vote in December, is nonbinding because middle schools set their own admissions criteria. But a show of support from parents could lead to action from the education department, which has been prodded by integration advocates to make other changes in high school and middle school admissions.

This summer, the department announced it would end the practice of “revealed rankings,” which allowed middle schools to select only those students who listed them first or second on their applications. The city is also appointing a committee of parents, educators, and community leaders in Brooklyn’s District 15 to come up with a proposal for making that district’s middle school applications process more fair.

“We’re collaborating with communities across the city to make school admissions more equitable and inclusive, including in District 2,” said department spokesman Will Mantell in an email. The department looks forward “to further conversations about this resolution and other efforts to improve middle school admissions in District 2.”