Purposeful sampling was used to select a diverse set of participants based on demographic (eg, race/ethnicity, gender, profession, urbanicity) and circumstantial (eg, availability) variables that were important to this study.¹⁵ We invited 8 to 12 participants to each focus group, a number recommended to ensure that each individual participant is heard while still maintaining a range of perspectives.^16,17 Interview participants who were health care providers outside of the school setting were selected based on their medical expertise and the specific settings in which they work (eg, emergency departments, pediatrics, and concussion-specific clinics). Based on recommendations for reaching saturation,¹⁸ 12 community-based health care providers were interviewed. Participants were recruited through contacts in sports organizations, medical facilities, school districts, project advisory board members, and social media. Researcher contacts and project staff announced the research opportunity via email and using social media posts on relevant sites with permission. Each email or post explained what the research was about and provided the email of the project’s research assistants.

Stakeholders reported a significantly lower incidence of brain injuries during the pandemic, particularly while organized sports were suspended. One pediatrician said, “I would say, I definitely have seen less concussions because kids aren’t playing sports and aren’t hanging out together as much.” Another medical provider, who was based in a concussion clinic, explained in more detail what medical providers had been noticing and provided some insight into the potential trajectory of brain injury incidence:

Overall, we looked at our [head] trauma numbers, you know about a year ago, and even into the spring, they are drastically down from things like sports activities, playgrounds, falls, this sort of stuff and so because of that, overall, the volume of kids that we’re seeing with brain injuries has come down. Now, I expect with vaccination now coming up, particularly in the 12 to 15 age group, you know the 16–17 year olds now have been eligible for a while, and I think with adults becoming progressively vaccinated and people getting back to some of these activities, I think we will start to see an uptick in this, but … those numbers are way down.

Stakeholders reported that the increased screen time caused by school logistical changes during the pandemic exacerbated the symptoms of TBI in students. One high school student explained that it caused previous symptoms, which had mostly remitted, to return and require further attention:

With having to switch to online, it actually made me more aware of my symptoms. Because it was like a year, over a year ago that my last one happened. I kind of just was used to like, oh, they’re probably gone or somewhat have kind of eased up and then the moment I started doing hours a day online, I realized that my focus, attention, and headaches … I started seeing my concussion doctor again just to see if there’s anything I could do … So, I think in some cases with people that are dealing with concussions now, or have in the past, I think the pandemic has helped um, in a negative way, at least kind of bringing those symptoms back up and have them reoccur.

A parent explained how she noticed increased difficulties with her child’s executive functioning:

I mean, he’s pretty tech savvy; I’m pretty tech savvy. And the first month of school, all I was getting was constant text messages of, “How do I fix this? I don’t know where to go. It’s not working right.” And then when there would be tests and a test would be locked because he didn’t show his face on the camera … there’s all of these like little glitches that typically as adults we get frustrated with but then to have a teenager who has poor executive functioning on top of a TBI, which affects his executive functioning, has just compounded, you know?

Although some medical providers did not describe specific cases of patients who had noticed screen time exacerbating TBI symptoms, all of the medical providers explained the importance of advising patients to decrease screen time after sustaining a TBI. Those statements were typically followed by the medical providers expressing a belief that remote-learning environments are not conducive to reducing screen time.

Stakeholders from schools noted that the remote learning environments resulting from the pandemic created new problems in providing accommodations to students who sustained a TBI. One educator described the situation by saying, “So that’s really difficult with distance learning right now … trying to figure out how to accommodate for kids with TBI when all of their learning is on a device.” The primary reason stakeholders gave for increased difficulty providing accommodations was a lack of ability to facilitate deeper relationships with students when all communications were remote. One special education teacher described it as not being able to know a student well enough to notice a difference in functioning:

And so, if you’ve got a student who has had a concussion or even a traumatic brain injury during the course of the school year, you know, unless that student alerts the school or the parents alert the school, there’s no way that we would even know because you’re not in contact with the kiddo enough to even go, “whoa, something’s really different,” or, you know, or you just might see a drop off in engagement.

A parent explained that because of the new COVID protocols, students at her child’s school transferred frequently between subjects and teachers, which added to the difficulty of receiving accommodations:

But more often, he was not on the radar. And the 1 teacher who I guess, you know, because they’re switching subjects. They’re switching like every six weeks, they’re doing six-week little terms and rotations in their classes. So, this was a new teacher that term. And so, I don’t know if it just kind of got forgotten. But it was, it was like, “You guys are on it. This is awesome.” And then it was, “Oh, bummer.”

Many stakeholders described how COVID safety protocols in schools exacerbated the mental health concerns brought on by TBI. A parent described her daughter’s experience:

Our oldest daughter was never like this; prior to her concussion she was very optimistic, very outgoing, very positive. But since the concussion, she’s definitely lost that about herself. She’s lost her ability to do her sports period. We have not regained that because of the loss of motor functioning. And then when you add the pandemic on there and the fact that she hasn’t been able to see her friends and see her cousins and see her family added to that stress. And she had the choice to do the online school but chose to do the distance learning, simply because it has interaction.

Educators also noticed a significant effect on the mental health of their students with TBI:

But this fall, I’ve noticed a huge decline in his mental health. He is irritable, he’s lonely, so lonely. Because on top of his social emotional stuff, he also has some awkward social skills and so we work on that with him but when you don’t have kids to work on that with him with, you know … I don’t think the world understands the effect on kiddos in general, but especially kids that are struggling with concussion, TBI, um, mental health. It’s really taking its toll.

Although the majority of stakeholders described how students’ experiencing a TBI’s mental health was affected negatively by COVID safety protocols, 1 medical provider did explain a scenario that she had noticed in which a student showed improvement in their mental health as a result of remote participation in school:

I’ve talked with some students who had a history of social anxiety or they were having issues with bullying at school or test taking anxiety, and the transition to more of an online format has been a lot less stressful for them. And consequently, they feel like they’re having fewer symptoms, and they feel like their academic performance has improved because they’re not dealing with some of those other triggers.

Another phenomenon addressed by stakeholders was an increase in the time required for students to return to school/play. Stakeholders such as this medical provider explained how the lack of ability for students to have in-school contact with other medical providers led to fewer appointments and opportunities to follow up in his clinic:

I think some of the other obstacles have been trying to keep that good flow of follow up in the clinic. So, when a student is in school, one of the things that we notice is that between the athletic trainers and all of the other points of contact throughout their day, if a student is failing to thrive during their concussion recovery, there are lots of pivotal people who tend to reach out to the parents, reach out to the student, reach out to us, and say, “Hey I think this person needs to be reevaluated.” And one of the things that I’ve seen with COVID is that it’s more difficult sometimes to have those consistent follow ups. And some of it is that people have been understandably cautious about coming into medical offices and really going anywhere … but I have noticed that from time to time, there will be longer intervals between when we check in with people.

The findings from this study suggest that COVID-19 safety mitigation measures might have been particularly challenging for students who experienced a TBI during the pandemic. Students with TBI reported in our study that remote learning often worsened their symptoms. The effects of screen time coupled with absences due to TBI-related symptoms and covid safety mitigation measures (eg, distance/remote learning) decreased some students’ ability to access online instruction. The changing logistics of remote learning from day to day was particularly difficult for students with executive functioning impairments.

Even before the pandemic, students with TBI experienced difficulties accessing appropriate support services.^24,25 Our findings suggest that the COVID-19 pandemic made the provision of services for students with TBI even more challenging. In an online learning environment, teachers found it difficult to identify the behaviors associated with brain injury. Without observing a student in the classroom environment and having regular interactions, teachers found it difficult to know whether the student’s focus, engagement, and overall well-being were changing. This was compounded by absences and inconsistent schedules due to quarantines. In an online learning environment, it is critical for school health care providers to communicate with teachers about students who might have experienced a TBI to identify whether students are struggling and provide training in the types of accommodations that could support those students.

When a student was found to have experienced a TBI, educators reported challenges in providing adequate accommodations and monitoring the efficacy of those accommodations.²⁶ This could be due, in part, to teachers themselves feeling overwhelmed by the pandemic and the new expectations surrounding online learning.²⁷ It may be more difficult to gauge whether a child is becoming fatigued during an online lesson compared to when a child is in the classroom. Learning via an online platform can be more emotionally and cognitively draining than learning in person^28,29; thus, 1 logical online accommodation is to allow the student to attend class with their camera off so they can lie down. Teachers could then follow up with the student via email or a chat to see whether they have questions about the lesson and inquire about their symptoms. A common accommodation for students with TBI is a flexible attendance schedule, which could be adapted for online learning by allowing the student to join class for part of the day or during specific intervals (eg, attend in the afternoon or during math and language arts). Furthermore, because attention, concentration, and memory difficulties can hinder organization and self-sufficiency, more frequent contact between the teacher and caregiver can help the student maintain engagement.

The social isolation of the remote learning environment might also increase the risk for mental health issues; both families and students reported increased mental health challenges during the pandemic.³⁰ Social connection is an important component of brain injury rehabilitation and recovery.³¹ School health care personnel can engage families in educational sessions and provide resources to help them recognize when their child is feeling isolated or struggling emotionally and respond with social and emotional support strategies. For example, the parent and child might generate a list of activities (eg, call a friend, take a walk with a sibling, play an interactive online game on a parent-approved platform) and have the child select one or more each day during times they feel bored or lonely.

Respondents noted that lower numbers of brain injuries were reported in both medical and school settings during the pandemic. Given the challenges of identifying a TBI in the remote environment, it is unclear whether fewer injuries occurred, if lower numbers of students were identified by health care providers, or if there was less communication between health care providers and school staff about students’ injuries. Remote learning continues to be part of the educational landscape,³² and it will be essential to develop identification methods that take those challenges into account. For example, instead of calling an attendance line to report the reason for a student’s absence from school, there could be an online portal through which parents could report a medical event that might affect their child’s performance or warrant accommodation in remote learning. That portal could include a HIPAA-compliant place to upload recommendations from a health care provider and share progress monitoring data.

School personnel also reported that return to play and learning for most students with a TBI was extended during the pandemic. Because of absences and modified school schedules, school-based health care providers were unable to regularly check in with students. School-based health care staff typically monitor students’ health status, academic progress, and socioemotional needs post-injury, recommending follow-up with primary care providers as needed. However, during the pandemic, students were often not seen consistently by community-based practitioners. Health care personnel in both school and community settings might need to develop alternative approaches for monitoring a student’s symptoms to ensure optimal care.

This study has several limitations. Because the sample consisted of participants from only 2 states, it might not be generalizable to all schools and students with brain injuries during the COVID-19 pandemic. States have varying return-to-school guidelines, and schools and school districts used a range of policies and procedures to support students with TBI. Second, aside from 1 younger student, data were collected from public middle and high school students and might not reflect elementary student experiences in schools during the pandemic. Third, focus group participation is voluntary; individuals who participated might have different experiences than those who chose not to participate. These results provide preliminary information about the educational experiences of students with TBI during the pandemic.

This study explored the perspectives of students, educators, and parents regarding the school experiences of students with TBI during the COVID-19 pandemic. The lessons learned can influence how educational services—both in person and remote—could be designed to better support students with TBI in the future. For this shift to occur, there is a significant need for professional development in TBI as well as for the development of communication pathways, monitoring protocol and other infrastructure supportive of students with brain injury.