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?”

Frequently asked

There are lots of ways schools teach English learners. Here’s how it works.

PHOTO: Andy Cross/The Denver Post
Lindsey Erisman works with 6-year-old students in an English Language Acquisition class at Denver's Cole Arts & Science Academy.

School district officials in Westminster this year signed an agreement with federal officials to change how they educate students who are learning English as a second language.

Similar agreements have also shaped how districts in Denver, Aurora, Adams 14, and Adams 12 educate their English language learner students. But many people, including parents and district insiders, may still have questions about the various complicated programs and requirements.

Although many of the language-education agreements are years old, most of the issues haven’t been resolved. In Adams 14, for instance, parents and advocates have protested a district decision to stop biliteracy programming, and have questioned the district’s compliance with its agreement to better serve English learners. District officials have pointed out that their obligation is teaching students English, not making them bilingual.

Now at least one charter school, KIPP, is looking to fill in that programming gap. Many other states have had a number of biliteracy and other bilingual programs at various schools for years, but Colorado has only more recently started to follow those trends.

So what’s the difference between the various language programs and services? And what is required by law and what isn’t? The following questions and answers might help clarify some of those questions as you follow the news around these issues.

Which students are designated as English language learners? Do parents get to decide, or do schools decide?

Federal guidance requires school districts have some way to identify English learners. Most commonly, districts survey all parents at school registration about their home language and the student’s first language. If that survey finds there might be an influence of another language at home, the student must be assessed to determine fluency in English. While the district has to identify all students who aren’t fluent in English as language learners, parents in Colorado can choose to waive the federally required services for their children. If so, the district doesn’t have to provide special services, but would still be required to monitor that the student is making progress toward acquiring English.

What educational rights do English language learners have?

English language learners have specific rights under the Lau v. Nichols Supreme Court case from 1974 and the subsequent Castañeda standards released in 1981. State laws also outline some requirements for school districts. Specifically, school districts must provide programs for all identified language learners to give them the opportunity to learn English and to access a comprehensive curriculum. The government does not state what that program should be, but provides some standards requiring that any program is theoretically sound and has a research base to support it. The program has to have qualified teachers, and a way to demonstrate that students are making progress in learning English and their academic content. While the civil rights officials consider many details to verify compliance, simply put, school districts have the legal obligation to identify students, serve them in a sound program, and monitor their progress.

What is the difference between bilingual education and “ELL services?”

Bilingual education (which is the program that has the most support for efficacy from the research community) offers students opportunities to learn in their native language while they are learning English. Bilingual programs can vary from short-term, or early-exit programs, to more longer-term developmental programs.

English language learner services do not need to provide opportunities for students to learn in the native language. Most commonly these services only offer English language development classes (generally 45 minutes per day). All other content instruction is offered only in English. ELL services are not bilingual.

What is English language development?

English language development must be a part of any program or model a district or school adopts. It is the class time when students are taught the English language. The government wants to see that English learners are given a dedicated time to learn English, when they are not competing with native English speakers. That means, often, English language development is offered as a time when students are pulled out of class to practice English, or as a special elective period students must take without their English-speaking peers.

The structure of this time period, who has access to it, or who teaches it, are areas commonly cited as problems by the federal Department of Education’s Office for Civil Rights.

Do students who are identified as English language learners retain that designation forever? What does it mean to be an “exited ELL?”

They’re not supposed to. Students who are English learners should be tested at least once a year to determine their English proficiency. When a student reaches a high enough level, school staff must determine if the student is now fluent in English. If so, the student becomes an “exited ELL.” The law requires districts to monitor for two years students who have exited and are no longer receiving services. There are, however, students who do not reach English fluency before graduating or leaving school.

What is the difference between being bilingual and being biliterate?

Bilingual generally refers to oral language in that bilingual people can understand and speak two languages but may not be able to read and write in those languages. Biliterate refers to being able to understand, speak, read, and write in two languages. Many people are bilingual but not biliterate. Biliteracy is considered to be a higher form of bilingualism.

What is the difference between dual language and biliteracy models?

Dual language and biliteracy models share many common components. Both models usually have biliteracy as their end goal for students. Dual language models may be “one-way” or “two-way.” One-way programs generally serve students who are designated as English language learners (also sometimes called emerging bilinguals). Two-way dual language programs include students who are native English speakers. The only major difference is that biliteracy models focus on using two languages in the language arts or literacy classes (reading and writing in two languages) whereas dual language focuses on using two languages across the entire school day’s curriculum.

What is an immersion model?

Immersion models traditionally are thought of as referring to programs primarily intended for students from the dominant language population to learn a second language. This is different from programs meant to teach English.

While native English students can choose whether or not to learn a second language, students who are English language learners do not have a choice in learning English.

What is sheltered instruction?

This type of instruction takes place in non-dual language schools, during regular content classes (such as math or science), and it’s one way schools try to make the content understandable to students who aren’t yet fluent in English.

This is especially common in schools where English learners speak a variety of languages. Crawford Elementary in Aurora, for instance, has had up to 35 different languages represented among its approximately 560 students. If there aren’t enough students who speak a common first language and also a teacher who speaks the same language as those students, then schools must teach through English, while making the English as accessible as possible.

In practice, this means an English-speaking teacher would use sheltered instruction techniques to help all children understand the lessons such as, physical props, a focus on building vocabulary, and sentence stems.

Denver designates schools as TNLI schools. What does that mean?

Denver created the TNLI label in 1999 to set the district apart from other bilingual program models. TNLI stands for Transitional Native Language Instruction. The Denver TNLI program is a transitional bilingual education program model with a label created just for Denver. It’s a model where instruction in Spanish is used to help students learn while they’re acquiring English, but still has a goal of making students fluent in English as soon as possible, at which point students move into mainstream English classrooms.

Is one of these models best suited for English learners?

Among researchers, it is commonly accepted that dual language or biliteracy models are the most effective to put English learners on par with their native speaking peers, in the long run.

Why do teachers have to be trained specifically to teach this population of students? What are teachers learning?

Educators and researchers say that teachers need to learn the differences and similarities between learning in one language and learning bilingually. Teachers need to learn about literacy methodology and how teaching literacy in Spanish (for example) is the same and different as teaching literacy in English. They have to learn how to teach English language development to students who are beginning to learn English (it is different than just teaching in English). These trainings also help teachers learn about cultural similarities and differences and about sources of culture conflict. Teachers need to be able to teach children English; how to use English to learn; and how the English language works. In bilingual settings teachers need to learn those three things for two languages. In short, the training needed to be a bilingual teacher is quite different. Colorado will soon require some of this training for all teachers.

What are the challenges districts have in offering these different programs? How do schools decide which type of model to offer?

The demographics of a district’s student population, and district politics play a large part in helping a district decide what model or program to use. Resources can also be a factor in deciding how to structure services or what programs to offer. In Adams 14, when the district leadership decided to pause the roll out of a biliteracy program, the district cited a lack of qualified bilingual teachers, among other things.

In Westminster, the school district’s unique competency-based approach, which removes grade levels and seeks to personalize instruction, was cited as a reason why the district had structured its English language development the way it had before the investigation by the Office for Civil Rights sought to change it.

Does Colorado provide guidance or oversight for how districts are doing this work?

The Colorado Department of Education offers some guidance for districts, but oversight of the districts’ compliance with what is required is limited. In practice, when parents suspect their children aren’t educated well, they have filed complaints with the federal government. In Denver, the complaints went through the Department of Justice. Investigations of most other metro-area districts have been conducted by the Department of Education’s Office for Civil Rights.

task force

Jeffco takes collaborative approach as it considers later school start times

File photo of Wheat Ridge High School students. (Photo by Nic Garcia/Chalkbeat)

The Jeffco school district is weighing pushing back start times at its middle and high schools, and the community task force set up to offer recommendations is asking for public input.

Nearby school districts, such as those in Cherry Creek and Greeley, have rolled out later start times, and Jeffco — the second largest school district in Colorado — in December announced its decision to study the issue.

Thompson and Brighton’s 27J school districts are pushing back start times at their secondary schools this fall.

The 50-person Jeffco task force has until January to present their recommendations to the district.

Supporters of the idea to start the school day later cite research showing that teenagers benefit from sleeping in and often do better in school as a result.

Jeffco is considering changing start times after parents and community members began pressing superintendent Jason Glass to look at the issue. Middle and high schools in the Jeffco district currently start at around 7:30 a.m.

The task force is inviting community members to offer their feedback this summer on the group’s website, its Facebook page, or the district’s form, and to come to its meetings in the fall.

Katie Winner, a Jeffco parent of two and one of three chairs of the start times task force, said she’s excited about how collaborative the work is this year.

“It’s a little shocking,” Winner said. “It’s really hard to convey to people that Jeffco schools wants your feedback. But I can say [definitively], I don’t believe this is a waste of time.”

The task force is currently split into three committees focusing on reviewing research on school start times, considering outcomes in other districts that have changed start times, and gathering community input. The group as a whole will also consider how schedule changes could affect transportation, sports and other after school activities, student employment, and district budgets.

Members of the task force are not appointed by the district, as has been typical in district decision-making in years past. Instead, as a way to try to generate the most community engagement, everyone who expressed interest was accepted into the group. Meetings are open to the public, and people can still join the task force.

“These groups are short-term work groups, not school board advisory committees. They are targeting some current issues that our families are interested in,” said Diana Wilson, the district’s chief communications officer. “Since the topics likely have a broad range of perspectives, gathering people that (hopefully) represent those perspectives to look at options seems like a good way to find some solutions or ideas for positive/constructive changes.”

How such a large group will reach a consensus remains to be seen. Winner knows the prospect could appear daunting, but “it’s actually a challenge to the group to say: be inclusive.”

For now the group is seeking recommendations that won’t require the district to spend more money. But Winner said the group will keep a close eye on potential tax measures that could give the district new funds after November. If some measure were to pass, it could give the group more flexibility in its recommendations.