Tips for Diagnosing, Treating Younger Patients with Concussion

Driven by events in professional sports, concussions have been in the news a lot recently, and as a result, there has been an increase in awareness of sports concussion in the pediatric arena as well. Legislation in all 50 states mandates removal from play when concussion is suspected and return to play only after clearance by a trained professional. Return to Play protocols from the 2012 Zurich Consensus Statement on Concussion in Sport have been broadly implemented to guide the safe return of professional and youth athletes back to the field.

Here at the Minds Matter Concussion Program at CHOP, we also understand that concussion in children means much more than just return to play, and as a result, we have developed Return to Learn protocols to help return children to school after an injury. We also know that concussion is not just about sports: Review of our data shows about 50% of patients with concussions sustained their injury outside of sports, with mechanisms including falls, striking or being struck by an object, and motor vehicle and bicycle accidents. In addition, we recognize that concussion in children is not the same as concussion in adults, and the younger the child, the more important it is to take into account developmental issues that might impact a child’s concussion recovery.

Most children (80% to 90%) with concussion will recover in an uncomplicated manner and fully return to all of their activities over the course of a few weeks, but 10% to 20% may have a prolonged course. Younger age may be a risk factor for longer recovery, and the presentation of concussion in younger children may appear vastly different from the stereotypical concussion syndrome observed in older adolescents and adults. While older children may complain of headaches, dizziness, difficulty concentrating, and balance problems, younger children may not complain specifically of these particular symptoms—either because they are not experiencing them or because, developmentally, they do not yet have the semantics to describe such symptomatology.

There is little research on concussion in children younger than middle school, and much of what we know derives both from our collective experience as well as the literature in mild traumatic brain injury (mTBI) in younger children. While it may not be a preferred term for parents to hear, concussions are a form of mTBI. Once important complicating factors such as skull fracture or intracranial hemorrhage have been excluded, be mindful that younger children may still suffer from symptoms related to the concussion or mTBI after a head injury.

In younger, school-aged children, besides assessing for typical symptoms seen in older adolescents with concussion, also be on the lookout for behavioral signs such as increased emotional lability, ranging from crying easily, becoming more clingy, or picking more fights with siblings, to increased tantruming and irritability or decreased self-control.

Many features observed by parents of younger children with concussion appear to be consistent with temporary developmental regression, similar to what is often seen with the birth of a new sibling. In these situations, it’s helpful to:

• Provide anticipatory guidance to reassure and help parents and young children better understand and cope with the regressive behavior
• Encourage parents to recognize that many behavioral issues after concussion are related to diminished cognitive stamina so they can anticipate and perhaps prevent a “meltdown” after a day that is longer or busier than the child can tolerate while recovering.
• Keep daily routines simple and low-key to help children pace themselves and minimize behavioral outbursts.
• Incorporate a lot of breaks into the routine, allowing children to recharge and recover from cognitively and physically demanding activities while they gradually regain stamina.

Interestingly, many of our younger school-aged children are able to return to school sooner than some of their high school counterparts simply because they have a nurturing and supportive school context that better lends itself to a more relaxed ebb and flow in the classroom routine. In addition, younger children also exhibit vestibulo-ocular deficits and symptoms following concussion. Younger children with persistent balance, headache, visual/oculomotor, or dizziness symptoms also benefit from intervention with a developmentally oriented pediatric vestibular physical therapist.

In short, concussions in children have their own unique pediatric twist, particularly in the younger set. Your specific training and experience with pediatric developmental and behavioral issues puts you in a perfect position to understand and address these issues in younger children with concussion, and CHOP’s Minds Matter team is here to support you in whatever way we can.

Concussion Patients in CHOP Care Network 2010–2014

Organized by age in years at first concussion encounter:

• 5–11 years old: 3,993 patients
• 12–14 years old: 4,764 patients
• 15–17 years old: 4,475 patients

References and Suggested Readings

Concussion Care For Kids: Minds Matter. Families can benefit from the easy-to-understand information on concussion. Available at www.chop.edu/concussion. Accessed May 29, 2015.

Master CL, Gioia GA, Leddy JJ, et al. Importance of ‘return-to-learn’ in pediatric and adolescent concussion. Pediatr Ann. 2012;41(9):1-6. Kaldoja M, Kolk A. Does gender matter? Social-emotional behavior in infants and toddlers with mild traumatic brain injury. Brain Inj. 2012;26(708):1005-1013.

DeMatteo CA, Hanna SE, Mahoney WJ, et al. My child doesn’t have a brain injury, he only has a concussion. Pediatrics. 2010;125(2):327-334.

McCrory P, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sports Med. 2013;47:250-258.

Mccrea M, Guskiewicz K, Randolph C, et al. Incidence, clinical course, and predictors of prolonged recovery time following sport-related concussion in high school and college athletes. J Int Neuropsychol Soc. 2013;19:22-33.