CHAPTER 2
The Aftermath: Effects of Concussions
This chapter describes what happens after a concussion, from the immediate changes in neurochemistry to the signs and symptoms that may be present in the days, weeks, and months following the event. The neuropsychological effects, including cognitive, physical, emotional/mood, and sleep symptoms are discussed in depth. Dangers signs are also described, which could be indicative of a more serious brain injury.
Next, there is a discussion of the effects of concussions at different grade levels: elementary school, middle school, high school, and even college. While the clusters of possible signs and symptoms are the same for all age groups, the way they manifest and are acknowledged by students of different ages can vary.
While most concussions dissipate in 2 to 3 weeks, some people experience persistent and prolonged symptoms. Possible long-term effects of concussion are explained in this chapter, including complications associated with multiple concussions, postconcussion syndrome, second impact syndrome, chronic traumatic encephalopathy, and brain injury and suicide.
PATHOPHYSIOLOGICAL AND NEUROLOGICAL CHANGES
Understanding the neurochemistry of a concussion can help students, parents, school personnel, and athletic personnel better understand recovery. It is easy for us to understand lacerations and broken bones because they are injuries visible either to the naked eye or on hospital scans. Students with these injuries return to school with bandages, slings, or casts. However, a concussion is a disruption of neurochemistry—the brain cells become disrupted and imbalanced. While research on the neuroscience behind concussions is still in the early stages—and largely based on animal studies or people with more severe brain injuries—it appears that a series of molecular and functional changes take place in the brain following concussive injuries.
It is believed that after a concussive blow, potassium ions flow out of brain cells and calcium ions flow in, resulting in an inefficiency of brain cells to properly deliver much-needed nutrients (especially glucose) to the brain (Giza & Hovda, 2001). These molecular changes hinder a person’s ability to engage in many, if not most, physical or mental activities. Figure 2.1 illustrates a normal, healthy neuronal connection. By contrast, Figure 2.2 depicts a neuron following a concussion and the neurometabolic cascade that disrupts cell functioning.
In the immediate aftermath of a concussion, this dysregulation of brain cells may be so significant that sitting up or keeping one’s eyes open is more than the brain can tolerate. This exertion can cause symptoms to flare or be exacerbated (Sady, Vaughan, & Gioia, 2011). This explains why the individual who has sustained a concussion may just want to sleep for the first few days following the injury. Chapter 5 provides more information on the rapid recovery process as cells reregulate in these first hours and days after a concussion.
Figure 2.1. Normal neuron. Courtesy of Maria Tedesco.
Figure 2.2. Neuron following concussion. This image illustrates the neurometabolic cascade and interrupted communication among neurons. Courtesy of Maria Tedesco.
SIGNS VERSUS SYMPTOMS
In the medical world, signs are objectively observable indications of a condition that others can see and report, whereas symptoms are subjective features noticed and reported by the patient. Signs and symptoms of concussion are generally evident very soon after the concussive injury. However, some of the signs or symptoms may be delayed; they may not show up for hours or days. Chapter 4 contains assessment tools that can be used in the school to assess the presence and intensity of these signs and symptoms.
Signs of concussion that may be observed by parents or guardians include those listed in Exhibit 2.1 (Centers for Disease Control and Prevention [CDC], 2010).
Symptoms reported by students are organized into four categories: thinking/remembering, physical, emotional, and sleep (Exhibit 2.2; CDC, 2010).
All of these areas can affect learning and schoolwork. For example, cognitive symptoms can affect the ability to learn and process information, keep track of assignments, and perform well on tests. Physical symptoms can affect a student’s focus and concentration. Struggles with school work can further exacerbate the emotional symptoms that were originally caused by changes in brain chemistry. Finally, sleep disturbances can obviously cause fatigue during the school day, further compounding all of the other problem areas.
EXHIBIT 2.1
Signs of Concussion Observed by Parents or Guardians
Appears dazed or stunned
Is confused about events
Answers questions slowly
Repeats questions
Can’t recall events prior to the hit, bump, or fall
Loses consciousness (even briefly)
Shows behavior or personality changes
Forgets class schedule or assignments
EXHIBIT 2.2
Symptoms Reported by Students
Emotional
Irritable
Sad
More emotional than usual
Nervous
Thinking/Remembering
Difficulty thinking clearly
Difficulty concentrating/remembering
Feeling more slowed down
Feeling sluggish, hazy, foggy, or groggy
Sleep
Drowsy
Sleeps more/less than usual
Has trouble falling asleep
Physical
Headache or “pressure” in head
Nausea or vomiting
Balance problems or dizziness
Fatigue or feeling tired
Sensitivity to light or noise
Numbness/tingling
Does not “feel right”
Concussion symptoms can vary from lasting a few minutes, hours, or days, to weeks, months, or even longer. Some symptoms may not appear immediately after the initial injury, but only after multiple injuries have been sustained. Concussion signs and symptoms differ from person to person; thus, youth who sustain concussions may not experience all symptoms and no single treatment works equally well for all instances of concussion (Aldrich & Obrzut, 2012). Concussion symptoms provide clues related to what is going on in the child’s or adolescent’s brain. The number and combination of symptoms can indicate which areas of the brain were affected by the concussion. An injury that was focal and isolated to one area may result in fewer, more short-lived symptoms. A more diffuse and widespread injury may result in a greater number of more persistent symptoms.
Symptoms may flare when the brain is asked to do more than it can tolerate. Students who are trying to “tough it out” can make their symptoms worse and prolong recovery. Until they have recovered, students should receive appropriate adjustments or accommodations in all settings, which are discussed later in this book.
Carly (First grade, playground injury)
After school on the day she fell from the monkey bars, Carly went outside to play with her younger brother, Henry. However, after about a half hour, Carly came back inside, saying she “didn’t feel good.” She went up to her room to lie down.
Later that evening, Carly began her math homework. After a few minutes she started to cry.
“I can’t do these!” she shouted.
Her mother looked over Carly’s shoulder. “Yes, you can. I saw you do the same type of problems last week. It’s nothing new.”
“No!” Carly sobbed. “I don’t feel good.” She covered her eyes with her arms and put her head on the table.
Both the physical and cognitive exertion caused by playing outside and focusing on homework, respectively, can cause symptoms to flare, particularly in the first few days after a concussive injury. Had her parents known she had fallen at recess, they may have taken Carly to be examined by a doctor so her family could get a more definitive diagnosis and recommendations for treatment. A physician would likely have told Carly’s parents that she had a concussion. The doctor also would have likely recommended both physical and cognitive rest. In this case, Carly’s parents sent her to school the next day, and the teacher reported to the nurse that she suspected Carly had a concussion.
DANGER SIGNS
A student should be taken to the emergency department right away if any of the signs listed in Exhibit 2.3 are observed. The child should be watched carefully, particularly in the first 48 to 72 hours following injury, for any of these signs. The presence of one or more of these “danger signs” may indicate an injury that is more severe than a concussion (CDC, 2010):
Ben (Fourth grade, football injury)
The evening after Ben’s tackle during a youth football game, his father asked him about the game.
“It was good,” he said. “We won.”
“Tell your dad about that major tackle, though,” his mother prompted.
“What tackle?” Ben asked.
“When that huge player from the Eagles hit you from the side and you went flying through the air!” his mother exclaimed. “You scared your sister and me to death!”
“Um, I’m not really sure,” Ben said.
“It’s just a good thing you didn’t hit your head,” Ben’s mother said.
“Did you get back in the game?” Ben’s dad asked.
“Oh yeah,” Ben said proudly. “I played most of the game.”
An hour later, when coming to the dinner table, Ben abruptly sat on the floor, put his head in his hands and moaned.
“Ben, what’s the matter?” his mother asked, kneeling down next to him.
“My head really hurts. It kind of hurt before, but now it really, really hurts.”
EXHIBIT 2.3
Danger Signs
One pupil that is larger than the other.
Drowsiness or inability to wake up.
A headache that gets worse and does not go away.
Slurred speech, weakness, numbness, or decreased coordination.
Repeated vomiting or nausea, convulsions, or seizures (shaking or twitching).
Unusual behavior, increased confusion, restlessness, or agitation.
Loss of consciousness (passed out/knocked out). Even a brief loss of consciousness should be taken seriously.
‘Aw, sweetie. I’ll give you some ibuprofen. Come have some dinner first. I made your favorite spaghetti and meatballs.” she said.
“Ugh, I’m not hungry,” Ben said. “I feel like I’m going to throw up.”
Ben did throw up—several times over the next 2 hours. He seemed “not himself,” and he exhibited increased confusion and agitation. Ben’s mother called her sister, a nurse, who said Ben should be checked out in an emergency department for a concussion.
Ben’s mother took him to the hospital. He received a CT scan and MRI, both of which showed up normal. He was, however, diagnosed with a concussion based on the signs he exhibited and the symptoms he reported.
Ben’s aunt offered good advice when she suggested that his mother take him to the hospital right away. Ben was showing some of the danger signs that might have indicated a more serious brain injury. As is evident in Ben’s case, the presence of several danger signs—unusual behavior, repeated vomiting, and an increasing headache—does not automatically indicate a severe brain injury, but they are signs that warrant an immediate and complete medical evaluation. In this specific case, although Ben exhibited a couple of the danger signs, he luckily had not experienced a more serious brain injury. He did, however, have a concussion that needed particular care and treatment.
EFFECTS AT DIFFERENT GRADE LEVELS
Elementary school
After a concussion, younger children tend to complain more about physical symptoms than older students. They may describe their head as feeling “like it’s being squeezed,” their tummy as feeling “yucky,” or their body as feeling “tired.” They may also act out more when experiencing cognitive overload and fatigue. They may have meltdowns, outbursts, or simply not act like themselves.
Elementary teachers likely have fewer students and typically know their students’ parents better than teachers of older students. Therefore, they may have greater responsibility in assisting a concussed student through the recovery process. The parents or teachers might want to talk with the student’s classmates to let them know that the signs and symptoms are not contagious and to give them ideas on how they can help and support their friend. Such ideas might include engaging in a quiet activity with the concussed student during recess or helping carry the student’s heavy bookbag.
Middle school
Friends and an active social life are increasingly important in middle school. The middle school student might try to hide concussion symptoms so he or she does not stand out or require special attention. Conversely, some middle schoolers may overdramatize symptoms in order to gain attention. As one physician who is a concussion specialist said, “With a lot of these middle schoolers, [on the 0–6 symptom rating scale] everything was a ‘6.’ Every day they were ‘dying’ but you know it really wasn’t that bad … but of course you can’t say that to them.”
The transition from elementary school to middle school can be difficult for many students, but particularly for a student who has sustained a concussion. The student may have already been grappling with the increased responsibility for self-management, organization, and planning ahead. The concussion can make these tasks much more difficult. Thus, it is important for the school to communicate clearly with the student, his or her parents, and the student’s medical providers so everyone has a clear picture of the student’s symptoms and specific areas of difficulty.
Damien (Eighth grade, car accident)
Damien was a bright and successful elementary school student. He easily earned good grades and his teachers generally liked him. The move to middle school was difficult for him. His group of friends were scattered among the students from the five other elementary schools—he almost never saw them. He had to change classes, manage a locker, plan projects and homework, and adjust his behavior and work to meet the expectations of seven different teachers.
By the end of seventh grade, he had it all figured out. He started eighth grade strong. Then he was in the car accident.
Damien not only experienced a concussion, but also a broken leg and lacerations. The night before he returned to school, it took Damien several hours to fall asleep. He had a terrible headache and was filled with anxiety about what to say to people and how to catch up on all the school work he had missed. However, he did not tell his parents how he was feeling and showed up at school the next day.
High school
High school students have moved even further from parents and more toward independence. A concussion can increase the need for parental monitoring and lead to a struggle or rift at home. For example, the effects of concussion can make driving inadvisable for a period of time. High school students may be angry or embarrassed at needing to be driven to school when they previously enjoyed the freedom of driving themselves. Managing the overall demands of high school life—homework, extracurricular activities, college applications, relationships, work—can be particularly challenging for a student who is suffering from the effects of a concussion. Parents and educators can help high school students prioritize their activities and reduce overall cognitive and physical demands. This, in turn, can help reduce symptoms such as fatigue, headache, confusion, irritability, and sleepiness.
High school teachers often work with more than a hundred students each day. It can be understandably difficult to monitor and meet the needs of one student who has sustained a concussion. The team model described in the next chapter gives educators support in this process. The student who seems disorganized, unprepared, and lazy might actually be suffering from a concussion; putting appropriate supports in place can help to minimize those kinds of behaviors.
College
Much of the information discussed in this book can be extended to the college setting. Underreporting of concussions is particularly prevalent in college populations (Kroshus, Baugh, Daneshvar, & Viswanath, 2014) despite the relatively high risk for sustaining concussions (Langlois, Rutland-Brown, & Thomas, 2006).
The level of independence expected by college students is high; however, because of limited experience with self-advocacy and self-care during an illness or injury, college students often do not admit that an injury has occurred. The very nature of a concussion results in impaired self-awareness; therefore, a concussed college student may not even suspect that he or she sustained a concussion. A roommate or residence hall advisor may think the student is simply exhausted or still feeling the effects of a weekend of hard partying. Such students often return to classes and sports prematurely without seeking appropriate help.
The college student who knows he or she sustained a concussion may still not take the appropriate self-care steps because the student is panicked about getting behind in school or doesn’t want his or her family to worry. The student might not want to cut back on hours at work or involvement in extracurricular activities. Further, college students may consume alcohol while still symptomatic, thereby putting themselves at increased risk for a second concussion before the first has resolved.
Even though it can be annoying to the high school student to have his or her parents hovering and monitoring symptoms, it can be dangerous for the college student with a concussion to not have that level of help and support. College students who have sustained concussions should seek help from their residence hall advisor, campus health services office, and/or office for students with disabilities. This can help ensure the student’s health and recovery are being monitored and that appropriate academic adjustments can be put in place during the healing process.
PERSISTENT AND SEVERE DIFFICULTIES
While most concussions heal on their own within 1 to 3 weeks, about 10% to 20% of individuals have persistent symptoms. This highlights the “crux of the [concussion] paradox”—that is, an injury considered mild may still result in lasting negative consequences (Comper, Bisschop, Carnide, & Tricco, 2005, p. 864).
Multiple concussions
Once a student has sustained one concussion, he or she is at three to six times higher risk for sustaining another concussion (Guskiewicz, Weaver, Padua, & Garrett, 2000). Sometimes the second concussive blow occurs with less force and often with a more prolonged and difficult recovery. With multiple concussions comes increased risk of persistent postconcussion symptoms. Concussions that occur in close succession—a second one before the first has resolved completely—can be harder for the brain to overcome and may take longer to heal.
Research on the cognitive and symptomatic outcomes of youth who sustain repetitive head trauma is mixed, but more studies report unfavorable changes than do not (Institute of Medicine & National Research Council, 2014). Although catastrophic results of second injuries are very rare, it is more likely that an overall cumulative risk associated with multiple concussions occurs, particularly when a second concussion is sustained before the first has healed. Risk of multiple injuries is particularly problematic in sports, due to both under-reporting of concussions, as well as premature return to play postconcussion.
Concussions often go unreported because individuals are unaware that an injury has occurred. Some may also consider the injury not severe enough to warrant medical attention. In the sports world, some athletes may deliberately choose to not report their injury because they fear losing their reputation, scholarship, or position on the team. Thus, they may return to the game before they are physically ready to do so (McCrea, Hammeke, Olsen, Leo, & Guskiewicz, 2004). This premature return to play can increase the risk of sustaining a second injury before symptoms of the first have resolved, thereby prolonging recovery.
Postconcussion syndrome
The term postconcussion syndrome has been used as a diagnosis for individuals who experience significant, persistent postinjury symptoms; however, the diagnosis is controversial, as it lacks a clear definition or consistent application. The most recent edition of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association [APA], 2013) does not have the previous edition’s (DSM-IV-TR [APA, 2009]) entry of a diagnostic definition for “postconcussional disorder.” Instead, the DSM-5 retained the broader “neurocognitive disorder due to traumatic brain injury” classification, which includes the diagnostic criterion of persistence “past the acute post-injury period” (APA, 2013, p. 624). A recent study found that 77% of youth who sustained concussions reported symptoms 1 week postinjury, 32% reported symptoms at 3 weeks, and 15% reported symptoms at 3 months (Eisenberg, Meehan, & Mannix, 2014). Another study found similar numbers at the 3-month mark, with about 13% of children reporting symptoms at 3 months postinjury—and 2% continued to be symptomatic after 1 year (Barlow et al., 2010).
In popular use, the term “postconcussion syndrome” or PCS generally applies to concussions that have symptoms which are severe and unusually long lasting. This often occurs as a result of sustaining multiple concussions or in situations involving a pre-existing medical or psychological issue. PCS is likely to affect:
Academic work
Classroom participation
Behavior
Relationships
Extracurricular activities
Sleep issues and depression are common in students with PCS. It is particularly important for school teams to assist students who have PCS; engaging them in school as much as possible without exacerbating symptoms can help mitigate the anxiety and depression that can arise in such cases.
Julia (Eleventh grade, soccer injury)
After sustaining her third concussion in 2 years playing soccer, Julia expected to recover within a couple of weeks, just as she did before. However, after several weeks, Julia still struggled with persistent headaches and nausea. She was lethargic and short tempered. Her parents encouraged her to get back into the swing of school and sports, thinking that a regular routine and exercise would help her feel better. Julia had been an honor student, but now her grades in school were slipping; her mother worried she was jeopardizing her chances at securing a soccer scholarship. Julia’s teachers were frustrated at what appeared to be her laziness and increasingly bad attitude.
Three months after sustaining her third concussion, Julia was scheduled to take the SAT college entrance exam. She came out of the exam in tears, complaining that her head hurt so much it felt like it was in a vice. She said she knew she did “terrible” on the exam and went home to bed for the rest of the day.
Julia’s parents finally took her to a doctor who specialized in evaluating and treating sports-related concussions. The doctor recommended eliminating cognitively and physically stimulating activities that exacerbated Julia’s symptoms, as well as avoiding loud, bright, overstimulating environments and technology. Although this made Julia’s social circle shrink further, it helped to alleviate her symptoms.
Julia’s parents regretted allowing her to go back to participate in soccer before her concussion symptoms cleared. Instead of missing only a week or two of practice and games, she was sidelined for the rest of the season during her junior year.
Second impact syndrome
Second impact syndrome is another poorly understood diagnosis. This is a potentially life-threatening condition that may result from a second (often minor) blow to the head before recovery from the initial injury has occurred. Second-impact syndrome is a very rare condition in which repeated head trauma results in brain swelling, causing the brain to burst within the confines of the skull, leading to herniation and sometimes even death (Byard & Vink, 2009). Those who survive are almost always severely disabled. Because this condition is very rare, there is little prevalence information and some researchers question its validity as a diagnosis entirely. Cases of second impact syndrome have only been reported in children and adolescents.
During a 13-year period, one research team found 94 cases of second impact syndrome, almost all of which were in high school athletes. About 75% of the cases were athletes who had sustained a pervious concussion during the same season (Cantu & Hyman, 2012). Although 94 is a low number when compared to the approximately 1.1 million youth who play high school football in any given year, most of these deaths could have been prevented. These cases can be particularly devastating for those who are left behind—the coaches who sent the player back into the game, the opponents who may have dealt the final tackle, the parents who consented to participation in the sport, and the teammates who knew that their friend was still suffering from concussion symptoms but returned to the field.
The 2006 case of Zackery Lystedt was one that prompted much of the current legislation that now regulates return to play guidelines in schools. Zackery was a 13-year-old who played linebacker for his middle school football team near Seattle, Washington. Near the end of the first half of a game, his head struck the ground after tackling an opponent. He was returned to the game in the third quarter. Near the end of the game, he was part of a big tackle at the goal line, which secured a victory for his school’s team. However, after the second half of the game, Zack collapsed on the field. He was airlifted to a medical center and had surgery to remove the left and right sides of his skull in order to relieve the pressure of his swelling brain (CDC, n.d.).
Physicians later indicated that Zack had suffered from second impact syndrome. A concussion that was sustained earlier in the game was not recognized and he was sent back into the game, where he incurred a second blow to the head that almost killed him. Zack was in a coma for 3 months. He did not speak for 9 months. He did not move an arm or leg for 13 months and was on a feeding tube for 20 months (CDC, n.d.). But he survived.
Three years later, Zack returned to school, and 2 years after that he graduated. He was still confined to a wheelchair, but walked across the stage with a cane to receive his diploma. Zack’s physical abilities, speech, and short-term memory remain impaired (Cantu & Hyman, 2012). In 2009, the Washington State legislature passed the Zackery Lystedt Law. The National Football League (NFL) refers to the Lystedt Law as model legislation pertaining to student athlete concussion. As described in Chapter 1, the three key provisions require: (a) education and signing of a concussion information form by coaches, parents/guardians, and athletes; (b) immediate removal from a game of any student suspected of having a concussion; and (c) medical clearance before returning to play from someone with training to recognize signs of concussion.
Chronic traumatic encephalopathy (CTE)
Mike Webster, an offensive lineman for the Pittsburgh Steelers in the 1970s and Pro Football Hall of Fame member, played professional football for 17 seasons. In his position, Webster was continually exposed to head trauma. In 2002, Mike Webster died at the age of 50. In the last years of his life, Webster was homeless, unemployed, deeply in debt, and in the process of divorcing his wife. Initial reports indicated that he had died of a heart attack, but the grim truth was later revealed. An autopsy showed damage in the frontal lobe of his brain. It is believed that this damage affected Webster’s thinking and reasoning abilities, as well as his attention and concentration, to such an extent that it incapacitated him. The pathologist who examined Webster’s brain, Dr. Bennet Omalu, asserted that a contributing factor to Webster’s death was chronic traumatic encephalopathy (CTE), a progressively degenerative brain disease that was previously only seen in boxers.
Dr. Omalu also found CTE in Terry Long, another deceased player who played for the Steelers, and who committed suicide by drinking antifreeze. Dr. Omalu believed that Long’s erratic behavior and depression toward the end of his life were linked to his diseased brain cells. The reaction to these findings was—and still is—quite controversial. The NFL had three scientists affiliated with the league write letters to a peer-reviewed journal demanding a retraction of Dr. Omalu’s published findings. Dr. Omalu’s story is at the center of a 2015 motion picture, Concussion, starring Will Smith.
CTE has been found postmortem in a number of football players since Dr. Omalu’s initial findings, including Junior Seau and Dave Duerson, both of whom committed suicide. Much is yet to be learned about CTE. What is known is that it is found in the brains of some people who have been exposed over many years to repetitive brain trauma, including concussions and subconcussive blows, which are repetitive hits not diagnosed or suspected as concussions. These jolts to the brain can trigger the buildup of tau—an abnormal and toxic form of protein—in brain cells. The process appears similar to that which takes place in the brains of individuals who develop Alzheimer’s disease. As the disease progresses, deposits of tau clog neural pathways and damage axons in the brain.
The medial temporal lobe is often affected in such cases, which causes victims to experience impaired functioning in memory and impulse control. Individuals can become depressed and have panic attacks. As the disease progresses, individuals afflicted with CTE may develop violent behavior. Their personal relationships can suffer irreparable damage.
Much remains to be learned about CTE, particularly because the disease can only be diagnosed after death, when the brain is sliced and examined under a microscope. Studies are underway that examine the use of biomarkers and advanced neuroimaging with the hope that there might soon be a reliable way of diagnosing CTE in living individuals. There is currently no treatment for CTE, and no way to slow the progression of the disease. At this point, the cause of CTE seems to be total brain trauma—not just a single concussion; therefore researchers are interested in learning more about the physical impact of the lighter slams and bangs—those multiple subconcussive blows—that are sustained by children who play collision sports. With practices and games, some children might sustain more than a thousand subconcussive blows in a single season, accumulating tens of thousands across their entire athletic career.
The recent discourse about CTE in adult professional athletes certainly has implications for our student populations. Seeing the potential of brain disease that athletic heroes can carry for the rest of their lives can lead to second thoughts when parents are deciding whether or not to sign up their young children for football. While CTE has not been named as the cause of death in adolescent athletes, there have been cases of early stages of CTE being identified in the brains of high schoolage athletes, including athletes who have died of second impact syndrome and suicide (Cantu & Hyman, 2012). This raises concerns about the possibility that repetitive brain trauma sustained in collision sports can start the process that results in CTE. And while this alone is not reason to do away with such sports entirely, it certainly is a good reason to consider changing some aspects of youth sports to make them safer, such as eliminating daily full-contact workouts for football players.
Brain injury and suicide
In some cases, the effects of concussions are so intense, and individuals become so distraught, that they become suicidal. Such students must be taken seriously and evaluated by an outside professional, such as a psychiatrist. The association between brain injury and suicide may be in part due to the unrelenting symptoms. The loss of things that are important to the individual—school, sports, cognitive abilities, previously enjoyed freedoms—can also be devastating.
In 2014, Kosta Karageorge, an Ohio State University football player, went missing after he left his mother a note that concussions had his head all messed up. He was soon found dead in a dumpster near his apartment with an apparent self-inflicted gunshot wound. Karageorge was also a wrestler, and his family cited his multiple sports-related concussions as contributing to the depression and confusion that may have led to his suicide (Oster, 2014).
Two years earlier, Jovan Belcher, a linebacker for the Kansas City Chiefs shot and killed his girlfriend and then himself. He was 25 years old and was diagnosed with CTE postmortem. Two years before that, a University of Pennsylvania football player, Owen Thomas, killed himself in his apartment and was later diagnosed with early stages of CTE. These cases represent some of the younger players to demonstrate links between concussions and suicide—a number of older players also committed suicide and were later diagnosed with CTE.
Warning signs that may assist in screening for suicide risk in patients with TBI are listed in Exhibit 2.4. Epidemiological research in the United States found that people with traumatic brain injury (TBI) of all severity levels had an 8% lifetime rate of suicide attempts compared with 2% of population as a whole (Simpson & Tate, 2007).
EXHIBIT 2.4
Warning Signs to Assist Screening for Suicide Risk in Patients With TBI
Depression/hopelessness
Relationship breakdown
Pressure of multiple stressors
Relationship conflict
Relationship isolation
Global impact of injury
Because the effects of a concussion can vary tremendously from person to person, symptom clusters and recovery rates also vary. Thus, it is important that educators know how to evaluate these symptoms and safely return students to the learning environment and any physical activities. Students who receive academic adjustments in school do so because they are still experiencing effects of a concussion—symptoms are still present. Students who are symptomatic should not resume physical activity. This can be a complicated decision-making process, particularly when a student has several teachers, coaches, and medical providers. A school-based concussion team can help streamline this process. The next chapter provides information to help such teams get started.
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