Concussion in Children and Adolescents

Introduction

Of the millions of male and female youth who participate in sports yearly within the United States, approximately 2 million children and adolescents sustain concussions, accounting for over 160,000 emergency room visits and hospitalizations annually. There is increasing evidence of the adverse effects of a single concussion on cognition and postconcussive symptoms, including poor attention, headaches, and fatigue. After a single concussion, a subsequent concussion is more likely and multiple concussions are often sustained in a short period. Given the morbidity associated with concussion, prompt diagnosis and treatment are crucial to promoting a complete recovery and preventing cumulative and long-term brain injury. This chapter provides an overview of the etiology of concussion and recommendations for screening, diagnosis, and treatment.

Definition/Symptom Criteria

The Quality Standards Subcommittee of the American Academy of Neurology defines concussion as a trauma-induced alteration that may or may not involve loss of consciousness. Concussions are considered a mild traumatic brain injury (TBI) and can occur with contact to the head or with acceleration/deceleration forces. In the 2016 Berlin Consensus Statement on Concussion in Sport, an expert panel defined concussion as follows:

• “Sport related concussion (SRC) is a traumatic brain injury induced by biomechanical forces. Several common features that may be utilized in clinically defining the nature of a concussive head injury include:

  • SRC may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an impulsive force transmitted to the head.

  • SRC typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. However, in some cases, signs and symptoms evolve over a number of minutes to hours.

  • SRC may result in neuropathological changes, but the acute clinical signs and symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.

  • SRC results in a range of clinical signs and symptoms that may or may not involve loss of consciousness. Resolution of the clinical and cognitive features typically follows a sequential course. However, in some cases symptoms may be prolonged.

• The clinical signs and symptoms cannot be explained by drug, alcohol, or medication use, other injuries (such as cervical injuries, peripheral vestibular dysfunction, etc.) or other comorbidities (e.g., psychological factors or coexisting medical conditions). ”

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition , characterizes concussion as a neurocognitive disorder, which is placed on a spectrum with more severe conditions. Diagnosis is based on a clinical presentation of a mild or major neurocognitive disorder. The distinction between these conditions is not based on the initial severity of TBI but instead on the severity of posttraumatic cognitive impairments and their effects on everyday function. Although the exact terminology and definition of concussion may vary among experts, the general consensus is that even relatively mild head injury without the loss of consciousness is sufficient to warrant the diagnosis of concussion.

Prevalence/Epidemiology

Approximately, one-half of all patients with concussion or mild TBI are between the ages of 15 and 34 years. Patients vulnerable to injury include children less than 5 years of age and those with lower socioeconomic status, lower cognitive function, and a history of prior hospital admissions. Since 2000, there has been a significant increase in the diagnosis of concussion in the outpatient and emergency department settings in children and adolescents with 4 in 1000 children aged 8–13 years sustaining an SRC. This may be due in part to increased awareness of concussion by patients, coaches/athletic directors, and healthcare providers.

Although boys playing collision sports (football, rugby, ice hockey, lacrosse) have historically had the highest incidence of concussion, girls playing soccer, lacrosse, and field hockey have also emerged as high-risk groups. When considering the role of gender in concussion, data suggest that adolescents with concussion exhibit gender differences with respect to risk factors, recovery, and symptomatology. Females are more likely to present with a concussion, experience more discomfort from a concussion, and seek treatment for postconcussive headaches. On the other hand, males are more likely to sustain a concussion from a contact sport and experience loss of consciousness, confusion, and amnesia with a concussion more frequently than females.

At the front line of concussion care is the primary care physician who routinely provides care for pediatric patients who have sustained a concussion during sports or other recreational activities. In one observational study of over 1000 high school students with SRC, approximately 60% of patients were managed by a primary care physician, whereas about 10% were managed by a specialist such as a pediatric neurologist or sports medicine physician.