Controversies In The Management of Concussion In Children and Adolescents


The primary aim of the pre-conference workshop is to identify some of the key controversies related to assessment and treatment of concussion in children and adolescents. The workshop is intended to be highly interactive, with emphasis on discussion and consensus building. The presenters are all very experienced clinician/researchers who will identify the key controversies and provide a synopsis of the current evidence related to the controversy. The audience will then discuss the controversy and will hopefully arrive at a consensus on how the controversy should be addressed.

JL: The first controversy to discuss is “when is a child with a concussion fully recovered?”. Recent research has provided irrefutable evidence of autonomic nervous system (ANS) dysfunction in children with concussion. More recent research has identified the fact that when children are asymptomatic and judged clinically recovered, they continue to demonstrate abnormalities in ANS function for up to a year post injury. What are the consequences of continued ANS dysfunction? Are there possible long-term consequences of ANS dysfunction? Should children who continue to demonstrate ANS dysfunction be allowed to return to sport?

ME: Although rare, there are reported cases of mental health breakdown and even suicide for children who have experienced concussion. The evidence for a direct relationship of mental health issues and concussion is limited by the rare nature of the problem. However, the consequences are substantial for the children affected and their families. Is there reason to believe that mental health issues can result directly from concussion or are there alternative explanations for the finding? What can clinicians do or look for in order to provide the best concussion management protocol for children at risk?

VA: While there has been considerable attention to protocols for safe return to sport after concussion there has been far less attention paid to establishment of guidelines for return to learning activities. Follow up studies have shown children after concussion can have academic difficulties for many months past the time when they were judged recovered. Should there be guidelines specific for return to cognitive activities? Are there cognitive markers for slow to recover children? Are there pre-injury markers for slow to recover children?

DT: Most of the research on children has actually focused on adolescents. Do the findings on adolescents generalize to children (<12)? For example, is the use of exercise tolerance testing appropriate and valid for young children? Can these young children accurately portray their symptoms and report on their state of health and mental health? How useful is neurocognitive testing in young children? Are there special considerations when managing return to school in young children?

BW: There is considerable controversy surrounding the existence and risk factors for chronic traumatic encephalopathy (CTE). Is there sufficient evidence of CTE and other long term consequences to begin to question the sports we allow children to participate in or the rules for these sports? For example, should we restrict children from body checking in hockey, or tackling in football or heading in soccer? At what age should body contact be introduced to sports?

Learning Objectives:

  • Describe the known mental issues associated with concussion in adolescents and children including the rates of anxiety and depression that occur, and the factors associated with these outcomes.
  • Articulate the known indicators of recovery from concussion including a return to pre-injury symptomatic state, achieving a state of exercise tolerance, and demonstration of cognitive recovery and when one or more of these factors is in disagreement with clinical assessment of recovery by a health care professional.
  • Identify the relevant research findings on the short term and long terms effects of concussion and the various factors that place children and adolescents at risk for incomplete recovery.


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