The soccer ball hit Marlo McElroy like a bullet to her forehead. Sideline spectators gasped.
"She didn't lose consciousness," recalled Marlo's mother, Tracy McElroy of Wildwood. "But by the time I got to her a few minutes later, her eyes were glassy and rolling back in her head. She wasn't able to answer questions like, 'Who's the president?' or 'When is your birthday?'"
That was seven weeks ago. Marlo, 12 and a seventh-grader at Rockwood Valley Middle School, was subsequently diagnosed with a concussion. She has been on "brain rest" ever since.
The Missouri Youth Sports Brain Injury Prevention Act became law this year. When student athletes are suspected of having a concussion or brain injury, the measure prohibits them from returning to practice and games until specific medical steps are taken and they have fully recovered. Illinois passed a similar law.
Neither law specifies measures for the classroom. But doctors are already writing an increasing number of orders to lighten the academic workload for children with concussions.
"We are seeing more kids that we have to make accommodations for," said Andrew Loiterstein, principal at Rockwood Valley Middle School. "I don't know if it's because they are having more concussions or if they are getting better at identifying them."
At least three students in the Parkway School District have turned over doctors' orders for brain rest this semester, said Lisa Harnacker, manager of health services for the district.
She suspects it stems from efforts to make people aware that concussions "are not just a quick little weekend thing and the kid is ready for school on Monday. That it affects the brain and ability to learn," Harnacker said.
The federal Centers for Disease Control and Prevention estimates that 173,300 children and adolescents, ages 19 and under, suffer concussions during sports and other recreational activities nationwide each year. Symptoms include headaches, dizziness, nausea, confusion, amnesia, a vacant stare, slurred speech, feelings of fogginess and, in some instances, loss of consciousness.
Experts aren't entirely sure what happens inside the brain when it suffers a concussion, because neuroimaging doesn't reveal anything unusual.
But they do believe the injury can lead to lifelong impairment to memory, behavior, learning and emotions.
Most research on sports-related hits to the head have focused on National Football League players.
The Center for the Study of Traumatic Encephalopathy at Boston University has found the same neurodegenerative disease in more than 20 deceased college and pro football players.
"One thing we do know for sure, though," says Dr. Mark Halstead, director of the sports concussion clinic at Washington University and Marlo's physician, "is that it takes longer to heal when you are younger. That's been proven."
Exerting the brain seems to exacerbate symptoms and possibly prolong them, says Halstead, an expert on sports-related concussions among children. He compares brain rest to immobilizing an injured limb.
Marlo was diagnosed with a concussion by an emergency room physician the day it occurred. She was sent home with instructions to take Advil or Tylenol for her headache.
When she began vomiting every day for 10 days, her mother made an appointment with Halstead. He prescribed something stronger, which helped ease the pain but didn't entirely kill it. He also prescribed medicine for her dizziness that was causing her nausea and wrote out orders for brain rest.
That meant no school for five weeks, followed by a gradual return. Now that she's back, she leaves class two or three minutes early and carries a backpack so she can go directly from one room to another and skip her locker. She uses an elevator that's off-limits to most students and eats in a quiet room with a friend or two so she can focus on what they're saying. She's limited to one test a day, has a designated note-taker and can go to the nurse's office and rest when she experiences dizziness, blurred vision or headaches.
Marlo sat in her geography class one morning last week completing a district assessment on the levels of government. Her classmates were taking a quiz. They had already done the assessment several weeks earlier while Marlo was at home recuperating.
Geography teacher Becky Forristal read the questions to her and then underlined the key things for her to focus on.
"Sometimes, if I'm trying to read a paragraph, I can't understand it," Marlo said. "I skip words and whole lines, especially when looking at a computer screen."
Doctors still don't know exactly how much brain rest a child with a concussion needs. Marlo's symptoms and the length of her recovery are not unusual, Halstead said. But he will not predict for any student-athlete how long it will take until their symptoms subside and they can conclude brain rest.
Eighty percent of student athletes recover within three weeks. But the other 20 percent experience post-concussive syndrome, which was historically known as shell shock. It can last for months.
Halstead recalls treating a boy who fell and was knocked out during a basketball game and spent a night in the intensive care unit. He was completely symptom-free two days later. Then there was the girl who was hit on the head with a dodgeball. She experienced symptoms for four months and took three medications to alleviate them.
The effects of concussions on students should become clearer in months and years to come.
Halstead is trying to get funding for a 15-year, multisite study to look at the long-term effects of concussions on young athletes and what treatments work best.
The Missouri brain injury act requires state scholastic sports organizations to collect data and publish a report each year about the long-term effects of concussions and head injuries on student athletes.
Harvey Richards, associate executive director of the Missouri High School Activities Association, has been spearheading that effort.
He's working with a panel to put together a survey that will be distributed to Missouri high schools to track the number of students reporting concussions. The survey will inquire about the severity of the concussions and the medical treatment and in-school measures taken for the students.
The association also has been educating coaches, teachers, school officials and nurses, parents and students about the signs, symptoms and the long-term effects of concussions.
"We're trying to educate them that a kid who gets his bell rung on Friday might not be ready for class on Monday, and that it's not because he's not trying, but because he can't," Richards said.
The push to educate appears to be working.
Steve Berry, athletic and activities director at Lafayette High School in the Rockwood School District, said not only have the number of doctors' orders for brain rest increased, but so has the detail that goes into them.
"And because there is that medical note, those teachers make as many modifications as they can," he said.
In the past, nurses at Lafayette High sometimes experienced push-back from teachers, he said. Not anymore.
"The nurses believe it's because it's become more high-profile," Berry said. "And the teachers are starting to understand the degree of symptoms and how it affects performance in the classroom."
Some schools, like those in the Ferguson-Florissant School District, have become active in pinpointing young athletes with concussions and determining whether they need accommodations in the classroom.
"Our protocol is that the athletic trainer would follow up with the school nurse and the nurse will follow up with the kid's schedule," says Aimee Cacciatore, director of student services in the Ferguson-Florissant district. "We then call parents to see if they received notification and what follow-up they have done with the doctor and what he's recommending with respect to restrictions."
Cacciatore recalled that the first time a doctor wrote out orders for the classroom, earlier this year, the school nurse was so concerned that she called the doctor to ask whether they should change the way the student moved around the building.
"The doctor said, 'No, no, it's just brain rest.'" Cacciatore said. "It was the first time we'd seen such a written document about classroom activities. Usually it's about P.E."
Halstead said many school officials are unaware that a concussion should be treated with brain rest. He has co-authored a concussion report for the American Academy of Pediatrics and is trying to persuade the organization to develop a list of detailed recommendations and a guidance statement for health care professionals and teachers for the classroom setting.
"The emphasis so far has been on returning to sports and not on what happens in the classroom, but that's an important part of it," he says.