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Preventing kids' concussion is about duty of care, not cotton wool

Concussions are mild traumatic brain injuries which cause the connections between brain cells to stretch or break. This can result in problems with attention, memory, balance, sleep, decision speed and…

Over the last year, around 200 per 100,000 Australian children suffered a blow to the head or face. Tom Childers, CC BY-SA

Concussions are mild traumatic brain injuries which cause the connections between brain cells to stretch or break. This can result in problems with attention, memory, balance, sleep, decision speed and mental fatigue. Symptoms typically resolve within 14 days but in some cases subtle symptoms persist, especially in children and teenagers.

The causes of concussion vary depending on the group. Junior contact or collision sports players are at risk of of head injuries, as are young people who perform equestrian activities, even when wearing helmets. Other reported causes of concussion have nothing to do with organised sports, and include “mucking around”, bicycle or skateboard accidents.

Hospital-based figures suggest that over the past 12 months, around 200 per 100,000 Australian children suffered a blow to the head or face that caused alterations in consciousness (concussions don’t always involve being knocked out).

But the actual figures are likely to be around ten times higher. Many concussions in the eight-to-18 age group go unreported either because they’re not witnessed by an adult, or the child wants to avoid restrictions on their activities. Naivety about potential harms and a lack of resources for communities to properly manage head injuries also contribute to under-reporting.

Detecting those who have not returned to their own pre-injury level of functioning is important when deciding whether a child should risk going back on the playing field or if she or he requires continued support in the classroom. We’ve developed a school-based concussion assessment, management and education program that aims to do just that.

Long-term effects of concussion

Media outlets in Australia and the United States are reporting on the possible long-term effects collision sports players sustain from repeated blows to the head as though it’s a new concern.

But the scientific literature first addressed the question with boxers in the 1920s. With a significant neuropsychology focus in the 1980s, researchers found that a small but consistent percentage (“miserable minority”) of adult athletes did not recover well and the cumulative effects of repeated concussions left players progressively more impaired.

There is some current confusion between players' reports of persistent cognitive problems after multiple concussions – which should prompt immediate concern and management – and a more complicated debate about whether multiple concussions lead to the condition called chronic traumatic encephalopathy (CTE).

The link between repeated concussions in sport and CTE certainly raises many concerns as the effects may be delayed and have reportedly led to catastrophic outcomes for a select group of adult athletes. But the association has not been fully established. For that, we need more carefully controlled long-term studies.

Junior play

Each week, young children, teens and their parents see professional athletes suffering significant blows to the head and face. They are clearly dazed, but remain on the field.

Some may see this as setting a dangerous standard for being an athlete who is devoted to his or her team. But its affect on parent and junior athletes’ decision-making has not been studied.

Children should be removed from the playing field or other risky activity after any head injury that results in altered consciousness. Flickr: Barry Cable, CC BY-SA

The rules governing junior play restrict collision and tackling techniques. But concussions and other knocks still occur. Lack of coordination or playing skill can lead to accidental collisions or balls getting kicked into the head of an opposing player or teammate.

The response from parents, coaches and radio commentators to warnings about the risks of concussion is often: “do you expect us to just wrap them in cotton wool?!” The short answer is yes – at least for the first 72 hours after a knock to the head. Then, when they are free of symptoms at rest, experts can help plan a graded return to activity.

Assessing the damage

The causes of concussion vary, so it’s important that concussion-management programs for children and teens include more than just contact sports teams.

Our school-based concussion assessment and management program includes symptom surveys and tests students' cognitive abilities at baseline, and several times after any injuries, using an internet-based program CogSport (now called Axon Sports Test) or Headminder.

A key part of these programs is learning how much scores change due to practice, age, physical exhaustion over the season, and just normal variations among children at each age. To gain these insights, we developed the program in close collaboration with school staff and students, and involve GPs and neuropsychologists in post-injury follow-up.

Young equestrian athletes are at a similarly high risk of head injuries to rugby players. Flickr: Robert McGoldrick, CC BY-ND

In the past, we’ve seen professional athletes undergoing pre-season screening suggest their mates “go slow at baseline”, recognising that the pre-injury tests use reaction speed to judge mental abilities. They recognise that if they “fake bad” at baseline (go slower than they truly can), they will look less impaired after an injury when post-concussion scores are compared to where they were before.

If the baseline scores are invalid then the post-injury tests are less useful in judging recovery. Symptom questionnaires that rely on valid information from injured children or teens who want to return to play have also been notoriously problematic when judging recovery in some settings when the athlete is “faking good” or when no pre-injury symptom levels are available.

We used various behaviour-management and education strategies to overcome the challenges in collecting reliable and valid data that reflects how all students look before they suffer a head injury. We can then better judge what symptoms predated the injury – such as mild attention problems in a nine-year-old or occasional headaches in a teenager – and whether the acute effects of the head injury have resolved.

Reducing the long-term risk

Our concussion program aims to engage students in their own brain care. In collaboration with school coaches, parents, teaching staff and administrators, and the students, we design a program that fits with routine school assemblies and small group activities that link students to mentor teachers of their choosing.

We try to develop a culture among the athletes and coaches that promotes brain health as well as enthusiasm for their chosen activities. Its value was demonstrated recently when a high school graduate who continued to play footy at university suffered a fourth concussion in his playing career.

The coach did not allow him to return to play but did tell him to go home. Fortunately he was too impaired to find his car. His high school friends who also learnt the “take care of your mates” attitude from our collaborative program came to the player’s rescue and made sure he sought effective follow-up care.

His scores six weeks after injury – relative to his most recent baseline – indicated that his Headminder Concussion Resolution Indices were in the average range but not back to where he had scored previously. Average may not be good enough for an elite athlete who was in the superior range pre-injury. We were able to offer academic strategies and a rehabilitation plan was put in place and monitored by a neuropsychologist and his GP.

Many concussions in the eight-to-18 age group go unreported. Flickr: Nathan, CC BY-NC-SA

All schools could benefit from a similar program, provided they could be linked to proper medical and even remote neuropsychology oversight. The online programs can be accessed from anywhere with an internet link but the scope of the program may depend on the level of technological sophistication in a school.

The baseline online testing can be accessed for approximately AU$7 per child. In our approach with independent schools, school staff we train are involved in helping with baseline screening and programs have been linked to psychology training programs so additional labour costs were minimised. But unless funded by a research program, comprehensive neuropsychological assessment may incur additional costs.

What else can parents do? Support your children in their sporting pursuits but monitor head injuries carefully and seek expert care. Children should be removed from the playing field or other risky activity after any head injury that results in altered consciousness. The child should then be assessed by a properly trained health-care professional.

Despite their insistence, the concussed child does not know best and sometimes it may be necessary to find another sport or hobby.

Further reading: Repeated head injuries highlight gaps in sports concussion management