CHAPTER 1
Overview of Concussions
A concussion is a type of mild traumatic brain injury (mTBI) that can result in a constellation of problematic symptoms. These include cognitive, physical, emotional, social, and behavioral symptoms, all of which can affect students’ well-being and performance in school. Concussions have received a great deal of media attention in recent years—largely due to controversies in professional sports regarding the long-term effects of concussions sustained by athletes. However, school-age children are at particularly high risk for sustaining brain injuries. This age group is also at higher risk for prolonged recovery (Gilchrist, Thomas, Xu, McGuire, & Coronado, 2011). Yet, despite the fact that concussions are relatively common injuries, educators typically receive little or no instruction in concussion recognition and response.
While some think of concussions as injuries that primarily occur in athletes, a number of school-age children sustain concussions through accidents, falls, fights, abuse, and everyday play. A student may come to school on Monday morning describing a car crash she was in over the weekend. She may tell her teacher about going to the emergency department (ED). She may say that she is very tired and she may seem noticeably distracted. But the teacher may not know whether the student is suffering from the effects of a head injury or if she is simply tired from a long night in the ED. The teacher may think the student is distracted simply because the crash and hospital events frightened her. Likewise, a school administrator may have a boy come to the office after a fight and, seeing no blood or broken bones, be so focused on the disciplinary ramifications that he or she misses the fact that the student is confused and answering questions slowly—classic signs of concussion.
Adding to such ambiguity is the reality that because every child is different, every concussion is different. Some students may have an “obvious” concussion and receive prompt and thorough medical evaluations. But others may not be diagnosed for days. Some may miss school and then have persistent symptoms that affect academic functioning; others may recover quickly and need very few short-term adjustments to their school routines.
The positive news medically is that, with appropriate diagnosis and management, a full recovery is possible for most youth who sustain concussions. Thus, school personnel working at all grade levels need to better understand their potential roles and responsibilities in assisting students who have sustained concussions. The purpose of this book is to provide a concise manual to assist teachers and other school staff members to support the return of students with concussions to their academic and extracurricular activities.
WHAT IS A CONCUSSION?
A concussion is the result of a bump or blow to the head—or one to the body—that causes the head to move rapidly back and forth, as illustrated in Figure 1.1. While we typically recognize concussive hits to the head—the fall on a hard surface, the whack with a hockey stick, the collision with the dashboard during a car accident—concussions frequently occur with no contact to the head at all. A hard blow to the body—for example, during a football tackle—can shake the brain in the skull cavity so much that it can cause a concussion. These forces may be linear and direct, which tend to snap the head backward and then forward, or they may be rotational, which can be more damaging because they cause the brain to rotate and spin within the skull. These forces can cause the blood vessels and brain tissue to stretch and shear.
These jolts can change the way the brain normally works because they result in a disruption of neurochemistry. The forceful movement to the head results in an alteration of mental status, which manifests as confusion or disorientation. Brain function is temporarily disrupted. However, because concussions are largely a neurometabolic injury, they are not likely to show up on an x-ray, computed tomography (CT) scan, or magnetic resonance imaging (MRI; Difiori & Giza, 2010; Pulsipher, Campbell, Thoma, & King, 2011). Such scans may be run to rule out a more serious brain injury, such as intracranial bleeding or contusions, or a skull fracture, but they do not show a concussion. More details on the pathophysiological and neurological effects of a concussion are provided in Chapter 2.
Figure 1.1. Individual sustaining a concussive injury. Courtesy of Maria Tedesco.
Because they don’t show up on typical brain scans or blood tests, concussions can be difficult to diagnose. Currently, concussions are typically identified by observation and reporting of signs and symptoms rather than by a definitive medical test. Thus, if a parent reports that a child’s CT scan or MRI was normal, members of the school team should know that this does not eliminate the possibility that there may have been an injury that needs to be treated and monitored.
A number of misnomers have been applied to concussions in the past, many of which minimize our perceptions of their potential dangers. Calling them “bell ringers” or “dings” suggests that they are minor injuries and thus no cause for concern. Therefore it is very appropriate to describe concussions in strict medical terminology—as a type of mild traumatic brain injury. The word mild, when coupled with the word traumatic conveys more precisely the injury to the brain that has occurred. Less frequently, one might see or hear the terms head injury or head trauma used when describing a concussive injury; however, these terms can also encompass head injuries that are not concussions, such as skull fractures.
Traumatic brain injuries (TBIs) are typically classified as mild, moderate, or severe, based on scores on the Glasgow Coma Scale (GCS), length of posttraumatic amnesia, and loss of consciousness. Because concussions are mTBIs, they are usually associated with a high GCS (13–15), little or no loss of memory or amnesia, and brief to no loss of consciousness. A 2010 study of high school athletes indicated that only about 5% of their concussions resulted in a loss of consciousness (Meehan, d’Hemecourt, & Comstock, 2010), compared to the 10% that is widely reported based on older studies. In such cases, the loss of consciousness is typically very brief. The classification system of mild–moderate–severe is relatively subjective and is used to reference the severity of the initial trauma; it is not indicative of the long-term consequences of the injury.
PREVALENCE
The Centers for Disease Control and Prevention (CDC, 2014) estimates that in 2010, about 2.5 million ED visits, hospitalizations, or deaths were associated with TBIs. Approximately 75% of these were classified as concussions; however, because many people who sustain concussions do not seek medical treatment, accurate estimates of the prevalence of concussions are difficult to calculate. Taking into account all of the concussions that go unevaluated and undetected, the percentage of brain injuries that could be classified as concussion is likely much higher.
Many of these injuries occur in children—and many are related to sports and recreation activities. Close to 250,000 children in 2009 were treated in U.S. EDs for sports and recreation-related injuries that included a diagnosis of a concussion. Further, from 2001 to 2009, the rate of ED visits for such injuries rose 57% in this age group (Gilchrist et al., 2011). However, again, these statistics do not reflect the numerous concussions that were not treated in an ED or those that went entirely undetected.
Overall, youth from 5 to 18 years of age are at increased risk of experiencing both a TBI and a prolonged recovery (Gilchrist et al., 2011). Within this age group there is a bimodal distribution of TBIs, with incidence rates spiking among preschoolers, largely due to falls, and again in adolescence, largely due to motor vehicle accidents. For adolescents and young adults ages 15 to 24, sports are the second leading cause of TBIs, behind only motor vehicle crashes (Cantu & Hyman, 2012). The likelihood of an athlete in a contact sport (such as football, hockey, or lacrosse) sustaining a concussion may be as high as 20% each season (Cantu & Hyman, 2012).
Data from the National Federation of State High School Associations (NFHS, 2014) Injury Surveillance System indicate that over 140,000 high school athletes across the United States sustain a concussion every year—a number that doesn’t even account for nonsports concussion instances or those in younger students. One recent study estimated that nearly 33% of concussions in athletes still go unreported (Meehan, Mannix, O’Brien, & Collins, 2013). This certainly makes tracking injuries and outcomes a complex endeavor.
What do these large numbers about prevalence mean for personnel working in schools? Lewandowski and Rieger (2009) estimate that in a high school of 1,000 students, there is likely to be anywhere from 5 to 10 students per year who experience a concussion. Similarly, Bakhos, Lockhart, Myers, and Linakis (2010) estimated that approximately four in 1,000 children ages 8 to 13 and six in 1,000 children ages 14 to 19 visited the ED for a sports-related concussion.
Incidence rates of TBIs that result in hospitalizations or ED visits are higher in boys than in girls. However, when comparing concussion rates of male and female athletes in high school and college sports, studies found that females had a higher rate of reported concussions (Institute of Medicine & National Research Council, 2014). This may be due in part to physical differences between males and females that make girls more vulnerable to the type of athletic injuries that result in concussions. Because the female neck is not as strong as the male neck, girls’ heads move back and forth more quickly upon impact. While neck strengthening exercises may be beneficial, they are not enough to mitigate this increased risk. Furthermore, girls may be more likely to report concussion symptoms than boys.
Discussion related to rates of concussions sustained in sport versus nonsport is also complex. One recent study estimated that about half of concussions seen in U.S. EDs for school-age youth were sports-related concussions; the same study found that approximately 25% of sports-related concussion visits by children 8 to 13 years old occurred during an organized team sport (Bakhos et al., 2010).
However, because many concussions go unreported, this is not a complete data set. It also is difficult to discern what might be categorized as a “sports concussion.” Certainly, a concussion sustained in a high school football game would fall squarely in the “sports concussion” category, but there is a continuum of injuries that includes concussions sustained in the following venues:
School sporting events, such as a middle school soccer match
Organized school sport practice, such as after-school lacrosse practice
Nonschool youth athletic leagues, such as Little League Baseball
Athletic activities, such as a gymnastics class
Casual sport play, such as baseball in the backyard
Athletic recreation, such as skateboarding
General recreation, such as playing on equipment at the playground
Physical activity, such as dancing in a mosh pit
Physical engagement, such as fighting
Which of those activities would qualify as a “sports concussion”? As long as different people have different answers to that question, and as long as many concussions go unreported, there will be limited reliable data on the percentage of sport versus nonsport concussions. In the recent publication Sports-Related Concussions in Youth: Improving the Science, Changing the Culture (2014), the Institute of Medicine and National Research Council took a broad view of sport, defining it as any sort of vigorous physical activity that did not involve motorized vehicles. Thus, concussions sustained through such activities as playground recreation, physical education class, and ropes courses were included.
CAUSES
School professionals might work with students who sustain concussions from a range of causes, from a preschool student who fell off the monkey bars to a high school student who walked into a pole while texting. The sports and recreation activities associated with most TBI-related ED visits for children age 19 and under are listed in the following order of risks (Gilchrist et al., 2011):
1. Biking
2. Football
3. Playground activities
4. Basketball
5. Soccer
6. All-terrain vehicle riding
7. Skateboarding
8. Swimming
9. Hockey
10. Miscellaneous ball games
Falls are the leading cause of nonsport-related concussions, and they disproportionately affect the youngest and oldest citizens. More than 55% of TBIs of all severity levels among children ages 0 to 14 were caused by falls.
RISK FACTORS
The majority of concussions resolve within 2 to 3 weeks without prolonged complications; however, doctors cannot predict the outcome of a student’s concussion at the time of injury. Sometimes, a very forceful blow to the head results in few symptoms and a quick recovery. Other times, a student may sustain what seems to be a relatively mild hit and then have many symptoms for a prolonged period of time. Similarly, a student who initially seems fine may then have delayed symptoms, whereas another student who initially has significant symptoms may recover quickly.
Admittedly, some students are at higher risk for sustaining a concussion than others. These students include athletes, risk-takers, and students who are impulsive. Students who play football and hockey might immediately come to mind when considering sports-related concussions, but virtually every sport poses some degree of risk, including flag-twirling (and flag-dropping) color guard members, the volleyball players who collide and fall on hard surfaces, and the cheerleaders who toss (and, yes, sometimes drop) one another into the air. Swimmers can slip on a pool deck and land on their heads, baseball players can have unfortunate collisions with swinging bats or the opposing team’s base players, and divers can crack their heads on the diving board. Ask any physician at a sports concussion clinic for details, and you will likely hear dozens of stories of different concussion cases and outcomes. Once a student sustains a concussion, no matter the sport or circumstances, a number of factors can affect the manifestation of symptoms and the trajectory of recovery.
Other risk factors for more intense symptoms or for protracted recovery include students with a history of previous concussions and those who have a history of migraines/headaches. Similarly, students with a history of learning disabilities, attention deficit hyperactivity disorder (ADHD), or other developmental disorders may also be at higher risk, as are those with sleep disorders or previous mental health problems, including anxiety, depression, and other psychiatric disorders (CDC, 2010). Yet others appear to have no discernible risk factors, but for some unknown reason, they develop persistent postconcussion symptoms.
Childhood as a risk factor
More research is needed, but preliminary data indicate that young children are at particular risk for adverse effects of concussions. Much of this is related to developmental issues. The young brain is underdeveloped when compared to older brains. First, the myelin sheaths in young neurons are not fully formed. Myelin is the fatty tissue that covers the fiber tracts in the brain. Adult neurons are covered with a coating of myelin that protects against injury. Although adult brains can certainly still be damaged, myelin helps defend them against injury. In contrast, young brains have less myelin, leaving them structurally vulnerable to damage.
In addition to neuronal risk, the physical stature of young children also places them at risk for the adverse effects of blows to the head or body. Younger children’s heads and brains are proportionally larger when compared to their bodies than those of adults. This proportional matter is particularly pronounced in early childhood. And when combined with the weaker neck of young children—particularly females—this extra size and weight means that a child’s head cannot withstand the force of a hit the way a typical adult’s can. Some may argue that young children are protected because child-on-child physical forces are not as strong as those sustained in adult-on-adult collisions. However, the force that is transferred to the head may be greater due to these proportional differences. Children also have thinner cranial bones and a larger subarachnoid space in which the brain can move, as well as differences in cerebral blood volume. All of these factors can make them more susceptible to concussions than older individuals (Karlin, 2011).
An additional factor related to childhood risk is simply the increased risk of cumulative trauma. If young football players are engaging in full-body contact drills beginning in early childhood, the sheer number of potential concussive blows increases. Much of the emerging research on postmortem brains of athletes who developed chronic traumatic encephalopathy (CTE), a chronic degenerative brain disorder, indicates that both concussions and subconcussive blows (repeated hits to the head that were not necessarily diagnosed as concussions) can be risk factors.
Adolescence as a risk factor
The risk-taking behaviors among adolescents can put this population at increased risk for concussion. This may be in part because the adolescent prefrontal cortex, the area of the brain that is important in executive decision making, emotion regulation, and risk assessment, continues developing into young adulthood. To complicate the risk even more, today’s youth have an earlier average age of puberty when compared with previous generations (Biro et al., 2010). This leads to an interesting mismatch—and essentially a longer than ever time frame—of a propensity toward risk-taking spurred on by both the onset of puberty and by behavioral inhibition due to the developing prefrontal cortex (Institute of Medicine & National Research Council, 2014).
THE UNDERREPORTING OF CONCUSSIONS
Although there is now greater awareness among coaches and players about the dangers of concussions and the need for appropriate treatment, there remains a tendency to underreport known or suspected concussions. The culture, particularly among athletes, resists both self-reporting of concussions and compliance with concussion management plans (Institute of Medicine & National Research Council, 2014). The hesitancy of youth to acknowledge their concussions as “real” injuries is a serious problem.
Students who fail to report concussions can experience subsequent problems with a variety of untreated symptoms (Comper, Hutchison, Richards, & Mainwaring, 2012; Laker, 2011; Lewandowski & Rieger, 2009), including problems related to physical activity, cognitive ability, emotional regulation, and sleep (Halstead & Walter, 2010). Because concussions are not visible injuries, athletic and medical professionals heavily depend on the individual to self-report suspected concussions (Mainwaring, Hutchison, Comper, & Richards, 2012). Therefore, students—particularly student athletes—need to be repeatedly informed about concussion symptoms, possible consequences, and the importance of immediately reporting concussion signs and symptoms.
Of course, even when student athletes are better educated about concussions, they often fail to report them. The problem of underreporting of concussion is not well understood. A recent study, however, identified a number of reasons why college athletes failed to report known or suspected concussions (Davies & Bird, 2015). Critical barriers to reporting included not wanting to be pulled out of a game, not wanting to let down their team, and thinking that the injury was just not serious enough. These findings were similar to a 2004 study in which a large sample of high school football players from 20 schools revealed that they reported only about 47% of their concussions even though 30% had a previous history of concussion. In this study, the most common reasons for not reporting concussions were not thinking the injury was serious enough to warrant medical attention, not wanting to be withheld from competition, and lack of awareness of probable concussion (McCrea, Hammeke, Olsen, Leo, & Guskiewicz, 2004).
Clearly, educating youth about signs and symptoms of concussion is important, but education alone is not sufficient to address the problem. Many athletes know the signs and symptoms of concussion—and the potential for additional injury during recovery—yet they frequently choose not to report concussion symptoms to a coach or athletic trainer. Overall, there is a culture of resistance to reporting concussions. To add to this difficulty, concussions are often not appropriately diagnosed in the hospital. De Maio et al. (2014) found that of 218 children age 6 to 18 who met the Third International Conference on Concussion in Sport diagnostic criteria for concussion (McCrory et al., 2009), the majority were treated and released from a level 1 trauma center ED without a concussion-specific diagnosis or activity restrictions. Thus, school personnel should be aware that a student who sustained a significant blow to the head who is presenting with postconcussion symptoms—even without a diagnosis from the ED—may require adjustments and monitoring at school. In such cases, they should refer the family to a medical specialist with experience in concussion evaluation and management.
It is important that school personnel seek to clarify and address factors related to the intention of underreporting known and suspected concussions. They can also specifically address the concerns about reporting concussions that were identified in the two research studies described earlier. School personnel can also focus on the creation of a caring, informed community around school children and adolescents. Finally, it is also important to evaluate how individual student variables, such as the sport played, personal demographics, and so forth, may influence responsiveness to efforts intended to change the culture related to concussions.
Once again, because concussions are invisible injuries, they may be easier to ignore than a gash or a broken bone. However, just like torn ligaments or sprained ankles, concussions require care and attention through the recovery process. Overall, a new attitude needs to be adopted that views concussions as serious injuries requiring care and attention at home, at school, and on the athletic field.
CONCUSSION MYTHS AND MISCONCEPTIONS
In aiming for a truer understanding of concussions, it is helpful to understand what they are not. Concussions are not “dings,” or “bell-ringers,” or minor injuries. They are mTBIs that can have serious repercussions if not treated appropriately. A few more concussion myths must be dispelled. Several of these myths have some grounding in truth, but the distortion of fact has led to many misconceptions.
“If you didn’t lose consciousness, you can’t have a concussion.” This myth may be perpetuated because the first questions asked in cases of head trauma often are, “Did he lose consciousness?” or “Was she knocked out?” In fact, fewer than 10% of concussions likely resulted in any loss of consciousness. And even in these cases, the loss of consciousness was likely transient—occurring for less than a minute.
“Concussions that result in loss of consciousness are always more severe than those that do not.” While loss of consciousness is an important facet of a head injury that should be documented and considered, it is not always the case that a concussion that knocks someone out is more serious than one that does not. Again, every concussion is different.
“If someone doesn’t have symptoms right away, it’s not a concussion.” Concussion symptoms often are present immediately—but not always. For example, Kevin, age 13, was in a fight over the weekend. He ended up with a number of cuts and bruises, which he had treated at a local urgent care center. Back at school on Monday, however, Kevin complained of fatigue and difficulty concentrating and reading. Over the weekend, he rested and did not really need to concentrate or read. It was only when mental focus and cognitive exertion were required that his concussion symptoms became apparent.
“A child vomiting after a blow to the head means they had a concussion.” Although vomiting can be a sign of concussion, a child’s being scared or shocked after an incident can also be a cause for vomiting. For instance, Matthew was sitting on a tree branch that broke and he fell to the ground. His mother came out of the house screaming. Matthew jumped up, cried, and vomited. The incident was awful and terrifying for Matthew and his mother, but he had no broken bones, no cuts, and no concussion. Yet, along with other symptoms—severe headache, confusion, and dizziness—vomiting can certainly indicate the possibility of concussion or an even more severe injury. It is an important sign of concussion, but does not automatically mean someone has sustained a concussion.
“You have to get hit in the head to have a concussion.” A number of concussions occur without a direct blow to the head. Concussions can also be sustained from a blow to the body that in turn causes the head to whip and the brain to shift inside the skull. In fact, many concussions from football tackles occur this way. The brain can scrape or bang against the ridged surface inside the skull and neurons can be stretched and sheared to the point of injury. These forces can cause a concussion without a direct hit to the head.
“Helmets prevent concussions.” Helmets offer important protection against skull fractures and head lacerations. They are required gear in collision sports because they protect against focal blows in which force is concentrated in a small area. In some cases, they can help minimize the effect of a potentially concussive blow to the head. For example, in hockey, a player’s helmet can help protect the skull from an opponent’s swinging stick or the flying puck. The helmet’s hard casing is designed to spread the force of the blow over a wider area, thereby dampening the force and reducing the chance of concussion.
Holly, for example, was a hockey player who sustained such an injury. She had been playing for several years and was in her final game of the season. As Holly went after the puck at the end of the first period, an opponent also swung for the puck. The opponent’s stick hit the side of Holly’s helmet with significant force. In Holly’s case, the helmet not only reduced risk of concussion, it also significantly reduced the risk of a hematoma, or bleeding, in her brain, while protecting her from a skull fracture.
However, in another hockey incident, Gabe was skating at full speed when he collided with another player and fell on the ice. In this instance, the helmet provided much less protection against concussion. That is because in such a case, the whipping action of Gabe’s head and the acceleration force stressed his brain—the brain hitting against the inside of his skull caused the damage. The helmet offers little protection against this type of hit.
“My child’s CT scan and MRI were clear, so he did not have a concussion.” Generally neither CT scans nor MRIs can detect concussions. Hospitals typically administer these scans because they are looking for different types of injuries, such as bleeding or fractures. For the time being, the only way to find out whether or not a child sustained a concussion is through reporting of symptoms. In cases of very young children, who do not yet have the language to describe how they are feeling, it can be more difficult to determine whether they had a concussion. In these cases, physicians are looking more at observable signs and depending on reports from parents. Some computerized tests that measure reaction time and memory, such as ImPACT, which is discussed in Chapter 4, can also aid in the diagnosis of concussion, as long as there is also a baseline assessment of how the child performed on such a test prior to his or her injury.
“The harder the hit, the worse the concussion.” There is not always a direct correlation between the strength of the concussive blow and the intensity or duration of symptoms. The child’s age, physical condition, pre-existing conditions, and other variables can all factor into recovery.
“All concussions have the same set of symptoms.” While headache and confusion are commonly reported, it is important to keep in mind that no two concussions are alike. Some students will seem irritable and have difficulty sleeping. Others will have trouble concentrating or reading. If a teacher has had one student recovering from a concussion while in class, the teacher should not expect the next student to present the same way or to recover at the same rate. Individual symptoms and categories of symptoms will be discussed in detail later in this book.
“Concussions are a bigger problem for boys than girls.” As discussed in the “Prevalence” section, there are gender differences in concussions, but it is not as simple as being “worse” for one gender than for the other. Once again, symptoms can vary between genders. One study of high school athletes indicated females reported more somatic symptoms, such as drowsiness and sensitivity to noise, while boys reported more cognitive symptoms, including amnesia, confusion, and disorientation (Frommer et al., 2011). Girls may also be more likely to report their symptoms.
One 2007 study found that: (a) concussion rates in high school soccer were 68% higher for girls than for boys, (b) concussion rates in high school basketball were three times higher for girls than for boys, and (c) recovery time for girls was longer than for boys (Gessel, Fields, Collins, Dick, & Comstock, 2007). A later study yielded similar results, finding that in gender-comparable sports such as soccer and basketball, girls had a higher concussion rate than boys (Marar, McIlvain, Fields, & Comstock, 2012).
This issue may not be as straightforward as simply more girls than boys sustain concussions in these sports. It may be the case that athletic trainers pay more attention to girls’ signs and symptoms than to boys’, pulling them out of the game more readily and essentially protecting female participants more than males. Perhaps culture is a factor and boys are more encouraged to be tough and to shrug off injuries. Perhaps the varying numbers can be partially attributed to differences in training, whereby boys are better trained to handle the blows. Finally, as mentioned previously, a significant variable is likely the differences in body types, with boys having bigger and stronger necks than girls. The bottom line is that gender is a complex issue in terms of concussion rates and reporting.
“Concussions aren’t as bad for younger kids because their sports aren’t as rough” or “Concussions aren’t as bad for younger kids because their brains can bounce back more easily.” As described earlier, young children are uniquely vulnerable to the risk associated with head trauma. The young brain is still developing and it may take young children longer to recover from concussions.
“After three concussions, an athlete should stop playing sports altogether.” While multiple concussions may certainly contribute to the presence of persistent symptoms, there is no magic number that should determine the course of one’s athletic career. Thus, in addition to the number of concussions, students, their parents, and their physicians should consider other factors, including the severity of each concussion, the length of time between concussions, the force of the concussive blows, and the constellation of concussion symptoms. For example, after sustaining one concussion in elementary school, 15-year-old Elise fell on the pool deck and sustained a blow to the head of minor force. The injury resulted in a complex and persistent constellation of concussion symptoms, which may indicate that Elise has a low threshold for head trauma, an indication that needs to be taken very seriously. Elise had previously played on her school’s lacrosse team, but after her concussion, she and her family decided she would instead pursue her love of piano and art.
“Mouthguards prevent concussion” and “Sports headbands prevent concussion.” Mouthguards can protect the mouth during sports, and headbands can keep players’ hair out of their eyes, but they don’t prevent concussions. See the discussion on protective gear in Chapter 7.
“Most concussions in children are caused by football.” According to the CDC, more children sustain TBIs from biking than from any other activity. Very few girls play tackle football, which skews the numbers. Concussion rates due to football in boys under 10 are also lower than those due to bicycling or playground accidents. Football does, however, top the list of concussion rates in organized sports for children ages 12 to 17 (Ferguson, Green, & Hansen, 2013).
“Parents should wake their child who has had a concussion every 20 minutes.” The child or adolescent who is recovering from a concussion should be checked on periodically; however, keeping them awake is not necessary once a more serious brain injury—such as a brain bleed—has been ruled out. In fact, a good night of uninterrupted sleep is one of the best mechanisms of recovery for concussion. A physician can advise parents on the proper steps to recovery; typically, this will involve plenty of rest. Thus, interrupting this rest may prolong recovery.
CONCUSSION LEGISLATION AND POLICIES
Concussion laws and policies have now been established in all states requiring that a student athlete suspected of having sustained a concussion be removed from play. These policies generally stipulate that a written release from a health care professional is required before a child who has been removed from play due to a head trauma can resume participation in the sport. They also typically include stipulations requiring that athletic coaches complete concussion education sessions.
It is important that all school professionals become familiar with the specific language of the legislation that has been adopted by their home state. For example, each state may have different definitions of who constitutes a qualified health care professional. Furthermore, some districts may have more strict standards than those established by state law. Three tenets of model legislation include the following:
Education of coaches, officials, parents, and student athletes
Removal from play if a concussion is reasonably suspected
Clearance by a licensed health care professional for return to play
These rules typically cover, at a minimum, athletes playing on middle and high school teams. Some states have wisely elected to include legislation that also reaches into private youth sports organizations, such as Little League Baseball and Pop Warner Football. Many state concussion laws also require a gradual re-entry plan for sports with a step-by-step process. These laws often incorporate the “Return to Play” protocol developed at the Third International Conference on Concussion in Sport held in Zurich (McCrory et al., 2009), a protocol that involves a step-wise decision-making process for determining when an athlete is ready to resume practice and game play.
Efforts to develop a similar “Return to Learn” protocol have begun taking root in the past few years (Halstead et al., 2013). Such protocols can help students who return to school while still symptomatic. Upon returning to school, students often require physical, emotional, and academic support. Schools can play a crucial role in facilitating a student’s transition back to school postconcussion. Without adequate understanding and support—and policies to require that schools provide this support—students with concussions may experience prolonged symptoms, educational difficulties, and social/emotional/behavioral problems, all of which are discussed in more detail in Chapter 2.
CASE STUDIES
We will follow four students throughout this book. Each child sustained a concussion in a different way, at a different age, and with different outcomes. We will revisit each of these four students at various points. These illustrative case studies can provide useful discussion points for school teams using this book as part of their concussion team training. Although the real-world application of the cases can help make some of the issues more realistic, it is important that educators keep in mind that no set of cases can perfectly encapsulate all of the variables and nuances they might encounter when responding to concussion cases.
Julia
Julia was an eleventh-grade honors student and star athlete; she played both basketball and soccer. At the beginning of the fall semester, she sustained her third concussion in 2 years. Three months later, she continued to suffer from postconcussion symptoms, including headaches, difficulty learning new material, and a low tolerance for frustration.
Damien
Damien was an eighth-grade boy who was in a car accident that resulted in a broken leg, numerous cuts and abrasions, and a concussion. His family, teachers, and medical providers tended to focus first and foremost on his visible injuries. However, he was also struggling with concussion symptoms that made the transition back to school particularly difficult.
Ben
Ben was a fourth grader who played youth football in his community’s recreational league. During a weekend game, a player from the opposing league collided with Ben. There was no direct helmet-to-helmet contact, and Ben’s head did not hit the ground; therefore, his parents and coach did not think he could have sustained a concussion. However, that evening he was nauseous and, when asked by his mother, Ben said he could not remember the collision.
Carly
Carly was a first-grade student who fell headfirst off the monkey bars on the playground. The playground aide did not see the fall, but she sent her to the office. The school nurse was not in that day. The secretary had Carly lie down for the rest of recess and then sent her back to class. Carly’s teacher thought Carly seemed fine and no documentation or phone call home was made. That evening, however, Carly’s mother noticed she was acting strangely—she seemed unusually tired and very moody, despite sleeping well the night before. The next day, the bright lights and loud noises at school bothered Carly and she told her teacher she felt dizzy.
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