While concussions can happen at any age, any brain injuries in children warrant specialized assessment and approaches to intervention.
Approximately 500,000 children a year visit an emergency room for traumatic brain injuries (TBIs) – among adolescents they are the single largest cause of emergency room visits. Eighty to ninety percent of these are mild (mTBIs), or concussions, and are not life-threatening, but even a mild TBI may sometimes have ongoing effects. We know that up to a third of all adults who sustain a concussion experience persistent symptoms, but we don’t know what percentage of children do. With so many children being injured each year, though, even a small proportion of them suffering negative outcomes makes concussion a serious pediatric health problem.
Many mTBIs are sports-related, but children can also suffer concussions from falls, fights, or abuse. (These latter causes, of course, may warrant multiple levels of intervention.) Young children are more susceptible to concussion than adults are, not only because they are more likely to be active and involved in sports, but also because their brains are not yet fully developed and thus more vulnerable to injury.
Recognizing concussion in children can be more complicated than diagnosing it in adults, since a child may not be capable of articulating the more subjective symptoms of a concussion, such as feeling “in a fog” or vertigo. Other symptoms, including irritability, may be mistakenly interpreted as a behavioral issue rather than a sign of a brain injury. Some post-concussion symptoms affect higher-level cognitive processes, which a young child may not yet be using.
Children also have their own motivations for under- or overstating the symptoms of concussion, which can complicate the injury’s aftermath. Some competitive young athletes are so eager to get back on the playing field that they deny having any symptoms, or they downplay their symptoms, in order to get back in the game. Others may exaggerate their symptoms to avoid returning to school. While it is better to err on the side of caution and take all reported symptoms seriously, it’s prudent to pay careful attention to children whose symptoms seem inconsistent with the expected trajectory of recovery. Finding a balance between returning too soon and sitting out too long is an important and nuanced part of the plan for recovery.
Children are generally resilient, and plasticity – the ability for the brain to reorganize itself and form new connections – is generally at its strongest in childhood, so most children recover from concussion without medical intervention. While some rest (both physical and mental) is encouraged, recent studies demonstrate that complete inactivity is not recommended.
Research does show that children can take longer to recover from a concussion than adults suffering comparable impacts. Children who sustain one concussion are also at higher risk for a second concussion from an injury sustained soon after the first one. As with adults, a child can sustain a second concussion from a lesser impact than is generally required to produce one – that is to say, a relatively small bump to the head can cause a concussion in a child or adolescent who has sustained a recent earlier concussion. Children who have suffered a concussion are not only more likely to have another concussion, but the consequences of subsequent concussions are potentially even more significant. That makes it particularly important to ensure full recovery after a concussion, as it helps prevent future concussions and avoid cumulative damage from repeated concussions.
Concussion diagnosis and management always requires a multidisciplinary approach and team, but it’s especially true for children and adolescents. A full history and screening of the child should include an exploration of any other issues that may exist (such as attention or learning issues, or other difficulties or stressors). A comprehensive plan to address the child’s return to learn and return to play should incorporate the child’s presentation, history, and school context. All of this is best managed by a multidisciplinary concussion team with pediatric specialization to appropriately involve the child, family, and school.
The good news is that children who sustain a concussion almost always recover completely in a relatively short period of time. The best way to achieve a good outcome is to ensure that a child is evaluated and assessed by brain experts with special training in brain injuries.