Parents of Middle School Students

Scenario:
Your daughter returned from her Saturday traveling soccer game feeling more tired than usual and complaining about a headache. She took a nap and couldn’t eat dinner because she was feeling nauseous. When you asked her about the game she said her team won, but nothing else.

How can I tell if my child has sustained a concussion?

Experts believe that concussion incidence statistics are inaccurate and that many concussions go undiagnosed or misdiagnosed. Athletes in particular may be hesitant to report injuries because they want to stay in the game. Athletes have reported that despite recognizing symptoms of concussion in teammates, they still did not inform a parent, coach, or anyone—a decision with potentially dire consequences. Middle-school-aged children may be particularly likely to minimize their symptoms in an attempt to not stand out or appear different from their peers.

Community-based youth sports programs are different from interscholastic sports in terms of organizational structure, accountability, and training of coaches and staff. Often, the only adult in charge of a community-based sports event is a volunteer parent. Interscholastic sports are governed by rules established by the New Jersey Interscholastic Athletic Association and are bound by each individual school district’s board of education policy regarding protocol for injuries sustained during school sports events. Additionally, since the passing of the New Jersey Concussion Law, school districts must have a district-wide concussion policy in place. What would you do if you were the parent of the young athlete in the scenario described above? Whenever a concussion is suspected, the first thing to do is to see a physician or other qualified healthcare professional knowledgeable in the identification, treatment, and management of concussion. The Center for Disease Control and Prevention states that “Physicians can play a key role in helping to prevent a concussion and to improve a patient’s health outcomes through early diagnosis, management, and appropriate referral,” and that “Symptoms of a concussion may appear mild, but can lead to significant, life-long impairment affecting an individual’s ability to function physically, cognitively, and psychologically.” This is why it is critically important that parents are well informed about concussion and know the signs and symptoms of concussion. There is no one tool that can diagnose a concussion. Each concussion is unique because each individual is unique.


My son has had one concussion already. Should I still allow him to play football?

You may have heard terms like post-concussive syndrome or second impact syndrome. There is so much information about concussion that it is often confusing to identify what a parent should be most concerned with. Experts emphasize the importance of keeping good medical records about any concussion to help parents work with physicians and student-athletes to answer to the question “Should my child still be playing organized sports?”

Here are a few facts:

  • After one concussion, an athlete is at an increased risk for another head injury.
  • There is a cumulative effect of multiple concussions. Sustaining a number of concussions over several years increases the risk of negative effects on an individual’s functioning, including cognitive, physical, or psychological/emotional difficulties.
  • The more concussions an athlete sustains, the longer it takes to fully recover.

There is little evidence-based information about children and concussion, and currently there is no single diagnostic tool to identify a concussion. Experts agree that diagnosing a concussion “involves the assessment of a range of domains including clinical symptoms, physical signs, cognitive impairment, neurobehavioral features, and sleep disturbance.” [1]


What is in the law and model policy regarding middle-school-aged children?

The New Jersey Concussion Law requires that if a student athlete sustains a concussion (or is even suspected of having sustained a concussion) while playing in a game or practice, the athlete must be immediately removed from play and should not return to sports activity for the remainder of the day. Following removal from play, the athlete must be evaluated by a healthcare provider if available at the school, or an urgent referral should be arranged. Immediate removal from play is important, even if the athlete feels better on the sideline, because symptoms may not fully manifest until hours or days after the incident. The law also states that any youth sports team organization[2] that operates on school grounds must sign a statement of compliance with that school district or nonpublic school’s policies for the management of concussions and other head injuries. Therefore, if a concussion is suspected during a community sports event on school property, the mandates in the law apply the same as they would if the suspected concussion occurred during an interscholastic sports event at school.

The model policy contains the following protocol to follow when a concussion is suspected in interscholastic sports:

  • Immediately remove the athlete from practice or competition. If there is a deterioration of symptoms, loss of consciousness, or direct neck pain associated with the injury, a coach, parent, or guardian should call 911.
  • The school’s licensed healthcare provider, who is trained in the evaluation and management of concussion, should evaluate the injured student-athlete.
  • School personnel (Athletic Director, Building Administrator, Certified Athletic Trainer, School Nurse, Coach, etc.) should next inform parents/guardian that a concussion is suspected.
  • The school should provide the student-athlete with the district’s board-of-education-approved medical checklist and suggestions for management to give to the parent/guardian, physician, and/or other licensed healthcare professional trained in the evaluation and management of concussion.
  • The student-athlete must receive written clearance, from a physician trained in the evaluation and management of concussion, which certifies that the student-athlete is asymptomatic at rest and may begin the district’s graduated return-to-play protocol. Medical clearance that is inconsistent with district, charter, and non-public school policy may not be accepted and such matters will be referred to the school/team physician.

The model policy extends the law to cover return-to-play decisions for grades K-8 with targeted suggestions for different grade levels. It states that “Younger students (K-8) should observe the 7 day rest/recovery period (after they are symptom free at rest) prior to initiating the graduated return-to-play protocol” outlined in the Consensus Statement from the 2008 International Conference on Concussion in Sport. The policy also states that the graduated return-to-play protocol should be monitored by a physician trained in the evaluation and management of concussion as well as the parents/guardians of the student-athlete (school nurses may serve as advocates for communicating signs and symptoms to physicians and parents/guardians). Any time there is a re-emergence of symptoms, a student-athlete is to be returned to the school/team physician or primary care physician.

School districts can choose to provide guidelines for elementary and middle schools to follow in the event that a student sustains a concussion outside of interscholastic sports. Schools may also provide physical education teachers with interscholastic head injury training because of the contact sports they facilitate daily and the risk of students sustaining concussions during gym activities. In addition, because of the risk of contact sports and the dangers of sustaining a second concussion before the first has resolved, many students with concussion return to school with gym restrictions, making it imperative for physical education teachers to be on the same page as other staff. Including a requirement for teachers to attend concussion trainings will reinforce the relationship between concussion and cognition, academic accommodations, and the physical activity restrictions that are typically necessary following a concussion.