Ahead of the Game

The Parent’s Guide to Youth Sports Concussions

Chapter 4: Indentifying and Treating Youth Concussion: An Eight-Step Plan to Get Back in the Game

Here’s the good news: a growing number of colleges and high schools across the country have finally started taking concussion prevention and management seriously. By educating athletes on the signs and symptoms of concussion, requiring baseline and post-concussion neurocognitive testing, and — most important — removing youth athletes from play immediately following a brain injury (even a suspected on), we’re making great strides in protecting the safety of our children, and ensuring that they will have long, happy, and healthy athletic careers. There’s even a nationwide legislative movement afoot to require all schools and athletic programs to establish formal concussion-management programs.

Now, here’s the bad news: the majority of American middle schools and elementary schools, as well as most community and recreation-based sports leagues, do not have any kind of program in place to identify, prevent, or manage concussions. As most parents know, rarely will you find an athletic trainer or other health care professional at a soccer practice for 6 year olds, or on the sidelines at a peewee football game. Rarely have youth sports coaches been educated about the dangers of a brain injury, or even shown what to look for. That means that millions and millions of young children are not only at greater risk of sustaining a concussion, but are less likely to receive the proper care and medical attention when they do get injured. Parents and coaches are often forced to navigate the confusing world of concussion aftercare alone, without any sort of guidance about where to go, what to do, who to consult, or how to help their child on the road to recovery.

This chapter outlines a detailed eight-step plan to help athletes, parents, and coaches determine exactly what to do if they suspect that a child has sustained a concussion. I’ll also discuss alternative (less mainstream) therapies that have shown some anecdotal effectiveness in treating lingering symptoms and post-concussion syndrome. And I’ll explain the frequent need for academic accommodations at school, and suggest ways to ensure that your injured athlete is getting the help he or she needs.

Step 1: Preseason Baseline Testing

If your child’s school or sport team already has a formalized concussion-management program in place (one that incorporates neurocognitive baseline testing), then step one is easy — your child will be tested automatically in the preseason, before she ever sets foot on the field. It’s still a good idea to check that your child is eligible to participate in the testing program. Some schools, for example, due to limited financial resources, may choose to test only varsity athletes, or may opt to establish a baseline only once (typically during freshman year) without every updating the scores. Don’t just assume that your young athlete has undergone baseline testing, or that her baseline test is valid or up to date.

If there is no formalized concussion program in place, you can obtain private baseline testing from a sports concussion specialist. These are licensed health care professionals who have been trained in administering and interpreting preseason and post-concussion neurocognitive testing. Such individuals include neuropsychologist, as well as some physicians who specialize in sports concussion. A neurocognitive specialist can then store baseline data should it be needed for a post-concussion comparison in the future. To find a listing of neuropsychologists in your area, you can log on to the National Academy of Neuropsychology’s website (nanonline.org). Or, to find a listing of CICS and test sites, log on to the IMPACT website (impacttest.com). Be aware that health insurance companies typically will not cover baseline testing because it is considered a “well visit,” meaning there is no diagnosis or disease for which the child is receiving medical services. Be wary of organizations that allow you to take a baseline test in your home, without oversight or education from a concussion specialist.

Regardless of whether baseline testing is obtained in school or in a private clinic, be sure that your child, coaches, athletic trainers, and other school personnel have received some kind of training in concussion prevention and identification. The best way to identify a concussion is to know what to look for.

Step 2: Awareness and Vigilance

One of the most common questions I hear form both parents and coaches is, “How do I know if the athlete actually has a concussion?” Vigilance is key. Detecting a possible brain injury is relatively easy when there are obvious signs: if the child blacks out or can’t keep his balance, for example. (And in such cases, you should seek immediate medical attention.) Otherwise, parents and coaches should be familiar with the behaviors of the youth athletes in their charge, and should become active observers at practices and games. Watch out of blindside hits and rough tackles, and keep a particular eye on athletes who have experienced a concussion in the past.

Both during and after a practice or game, be on the lookout for any changes in speech, balance, thinking, behavior, attention, or emotional response. Check for signs of confusion, headache, vision changes, dizziness, ringing in the ears, or nausea. Listen for slower-than-normal answers to any questions you ask. In my clinical experience, an athlete who says he feels “fine” or “okay” following a hard hit has not given you enough information. Look the child directly in the eyes and ask, slowly and methodically. “Do you feel just like you normally would feel after a game? Does anything feel different than usual?” Pointed questions such as these may challenge the child to think more carefully about how he feels, and to describe any changes he may be experiencing. The answers to these questions can not only help you determine if an injury has occurred, but may also give you and your health care provider a better understanding of how your child usually feels. Sometimes, it’s difficult to determine whether some “symptoms” are the result of a concussion, or may have been present anyway. For example, maybe your child usually has a headache after a practice or game because she suffers from sinus allergies triggered by playing in a springtime soccer field. Or, she may sometimes feel a little dizzy due to mild dehydration when playing outdoors in the heat of summer. Perhaps your child suffers from chronic ear infections, which can cause a ringing in the ears. Make a note of this kind of information, and be sure to share it with your child’s doctor.

Step 3: Sideline Assessment

If you suspect that a young athlete has suffered a concussion, a responsible adult should assess for immediate signs and symptoms by asking the athlete a series of questions to determine how oriented he is, and whether a loss of consciousness has occurred. Most often, that job falls to an athletic trainer (preferably certified). If no athletic trainer is present to administer a sideline assessment test, or if there is no formalized concussion questionnaire available for use, then a parent or coach can ask some simple orientation questions based on the easy-to-remember five Ws: who, what, when, where, and why.

Who: Does the athlete know her own name? Does she know who you are?

What: What is the athlete feeling? Check for signs of amnesia, memory problems, headache, nausea, vomiting, visual disturbances (such as blurred vision), dizziness, fatigue, or confusion. Did the athlete black out of lose consciousness?

When: Does the athlete know the date, day, month, year, and approximate time of day?

Where: Does the athlete know where she is? Is she familiar with her surroundings?

Why: Determine if the athlete can explain why she is not feeling well, or why she is being examined. Can she recall events immediately before, during, and after the hit or collision? For example, can the athlete tell you that she was playing soccer against the Red Dragons when another player ran toward her and their heads collided?

As a parent or coach, you should also ask the athlete to perform some simple math calculations, depending on the child’s age and maturity (for example, “What is 10 minus 7?” “What is 5 times 4?”). Next, you can instruct the athlete to listen to a random string of single-digit numbers (such as “9, 6, 2”) and to recite the numbers back to you in order. If he is successful, ask him to repeat up to seven single-digit numbers in sequence. Take note of the athlete’s response to all these questions, and have the responses ready when you seek additional evaluation from a pediatrician, an emergency room doctor, or a neuropsychologist. Just make sure that any health care professional who examines the athlete is made aware of any preexisting attention or concentration difficulties, learning disorders, or ADHD, as these types of conditions can affect a child’s ability to answer post-concussion questions.

The US Centers of Disease Control and Prevention (CDC) has developed a handy Concussion signs and Symptoms Checklist that can be downloaded, in both English and Spanish, from the CDC website (www.cdc.gov/concussion) and used at the time of injury. A formalized sideline questionnaire called the Sports Concussion Assessment Tool (SCAT) is also available online in an updated version, SCAT2. You’ll even find a Sports Concussion Card in Appendix C of this book, to copy and glue onto your coach’s clipboard or hang on the refrigerator. But remember, no athlete with a suspected concussion should be returned to play, no matter how “well” he or she performs during a sideline assessment test. Some athletes may not demonstrate any significant symptoms until hours or days after impact.

Step 4: Medical Exam
Step 5: Expert Skepticism
Step 6: Post-Concussive Observation
Step 7: Following Doctor's Orders
Step 8: Managing Persistent Symptoms with Advanced Medical Consultations and Alternate Therapies