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Concussion Evaluation, Management, Return To Play Different For Younger Children

Report different symptoms; need for cognitive rest, gradual return to classroom, more conservative RTP recommended

The most recent international consensus statement on sport-related concussions ("Zurich consensus statement") [1] identifies several important differences in the way concussions are diagnosed and treated in children and adolescents:

  1. Children report symptoms differently: Because athletes younger than age 13 report  concussion symptoms different from adults, they require age-appropriate symptom checklists as a component of assessment;
  2. More input from parents and teachers needed: In assessing the child or adolescent athlete with concussion, a clinical evaluation may need to include input both patient and parent input, and possibly input from teachers and school personnel where appropriate;Taking standardized test
  3. Younger athletes need more cognitive rest: The concept of "cognitive rest" has special importance for younger athletes with concussion, including recommendations for 24 hours of strict cognitive and physical rest after concussion. [Note: a  2014 study[8] found that student-athletes who continued to engage in full cognitive activity after concussion took from 2 to 5 times longer to recover than those who limited cognitive activity]
  4. Gradual return to learn appropriate. The taking off of one or two days from school, returning only with medical approval, and returning to the classroom with appropriate accommodations developed with the aid of a pediatric neuropsychologist, where necessary, are recommended. 
  5. More cautious return to play. According to a 2012 study,[7] athletes ages 13 to 16 take a longer time to recover following concussion - measured with memory tests, reaction times, and a symptom scale - than athletes ages 18 to 22.  A more conservative RTP approach, including extending the amount of time for asymptomatic rest and/or length of the graded exertion in children and adolescents is recommended. 
To assess concussion in younger athletes, the Zurich consensus statement includes a Sport Concussion Assessment Tool for children ages 5 to 13 ("Child-SCAT3")[2] which is different in several significant respects from the SCAT3 for athletes 13 years and older. [3]

Different symptom scales  

The Child-SCAT3 includes symptom scales to be completed by the child different from the self-assessment in the SCAT3, and includes a set of questions directed to their parent: 

                                                            Child - SCAT3 Symptom Evaluation

CHILD REPORTNeverRarelySometimesOften
1. I have trouble paying attention        
2. I get distracted easily        
3. I have a hard time concentrating        
4. I have problems remembering what people tell me        
5, I have problems following directions        
6. I daydream too much        
7. I get confused        
8. I forget things        
9. I have problems finishing things        
10. I have trouble figuring things out         
11. It's hard for me to learn new things        
12. I have headaches        
13, I feel dizzy        
14. I feel like the room is spinning        
15. I feel like I'm going to faint        
16. Things are blurry when I look at them        
17. I see double        
18. I feel sick to my stomach        
19. I get tired a lot        
20. I get tired easily        
21. Difficulty remembering        
22. Visual problems


Parent reportNeverrarelysometimes often
The child:        
1. has trouble sustaining attention        
2. is easily distracted        
3. has difficulty concentrating        
4. has problems remembering what he/she is told        
5. has difficulty following directions        
6. tends to daydream        
7. gets confused        
8. is forgetful        
9. has difficulty completing tasks        
10. has poor problem solving skills        
11. has problems learning        
12. has headaches        
13. feels dizzy        
14. has a feeling the room is spinning        
15. feels faint        
16. has blurred vision        
17. has double vision        
18. experiences nausea        
19. gets tired a lot        
20. gets tired easily        


As with other symptoms scales in use, however, these new child- and parent-symptom scales have not yet been the subject of large scale, controlled studies to establish their effectiveness in identifying young athletes with concussion.  

The presence of multiple symptoms does not, in and of itself, determine whether a concussion has occurred; rather, it is information that can help a health care professional in making an overall diagnosis, gauging injury severity, assessing recovery, and, because of the unreliability of athletes' reports of being symptom-free, [4]  in making the all-important return-to-play determination.  

While concerns are routinely expressed about athletes underreporting concussion or their symptoms, symptom assessment remains a critical component of concussion assessment, ideally in combination with other functional [(e.g. neurocognitivebalance)] tests.[5]

Different "Maddocks" questions 

To determine a younger athlete's orientation to time and place, the Child-SCAT3 calls for a child to be asked four so-called "Maddocks questions"[6] than called for under the SCAT3[3] (which asks five slightly different questions):

  1. Where are we now?
  2. Is before or after lunch?
  3. What did you have last lesson/class?
  4. What is your teacher's name 

Gradual return to learn

Unlike the SCAT3 for older athletes, the Child-SCAT3 specifically addresses a child's need for cognitive rest after concussion, including:

  • at least 24 hours of rest after concussion;
  • avoiding any computer, Internet or electronic gaming activity if these activities make symptoms worse;
  • staying home from school for a day or two;
  • the need, in some cases, for parents, teachers, and health care professionals to develop a graduated return to school program, which will vary from child to child, but may include
    • Extra time to complete assignment/tests
    • Quiet room to complete assignment/tests
    • Avoidance of noisy areas such as cafeterias, assembly halls, sporting events, music class, shop class, etc.
    • Frequent breaks during class, homework, tests
    • No more than one exam/day
    • Shorter assignments
    • Repetition/memory cues
    • Use of peer helper/tutor
    • Reassurance from teachers that student will be supported through recovery through accommodations, workload reduction, alternate forms of testing
    • Later start times, half days, only certain classes.
  • No return to sport or play until he/she has successfully returned to school/learning, without worsening of symptoms, and obtained medical clearance to begin graduated, symptom-limited return to play protocol.

More conservative treatment recommended 

"Because of the different physiological response and longer recovery after concussion and specific risks (eg. second impact syndrome), related to head impact during childhood and adolescence," the Zurich consensus statement recommends a more conservative return to play approach, extending the amount of time of asymptomatic rest and/or the length of the graded exertion for children and teens.[1]

The timing of post-concussion neurocognitive testing for younger athletes may also be different. Typically performed when an athlete is reporting no symptoms, a neurocognitive assessment for children may be useful during the early stages following injury to assist in making return-to-school decisions, an assessment which is "best determined" in consultation with a trained pediatric neuropsychologist, says the Zurich consensus statement, "particularly [for] children with learning disorders and/or ADHD who may need more sophisticated assessment strategies."  


Looking for more information about concussions? For the most up-to-date and comprehensive concussion information for sports parents on the web, check out the MomsTeam Concussion Center.

1. 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.

2. Child SCAT3. Br J Sports Med 2013;47:263. 

3.  SCAT3Br J Sports Med 2013;47:259  

4. Sandel N, Lovell M, Kegel N, Collins M, Kontos A. The Relationship Of Symptoms and Neurocognitive Performance to Perceived Recovery From Sports-Related Concussion Among Adolescent Athletes. Applied Neuropsychology: Child. 2012; DOI:10.1080/21622965.201 2.670680 (published online ahead of print 22 May 2012)(accessed June 5, 2012) 

5. Mcrea M, Iverson G, Echemendia, et al. Day of injury assessment of sport-related concussion.  Br J Sports Med 2013;47:272-284.

6. Maddocks DL, Dicker GD, Saling MM. The assessment of orientation following concussion in athletes.  Clin J Sport Med 1995;5(1):32-35.

7. Zuckerman SL, Lee YM, Odom MJ, Solomon GS, Forbes JA, Stills AK. Recovery from sport-related concussion: Days to return to neurological baseline in adolescents versus young adults.  Surg Neurol Int. 2012;3:130. Epub 2012 Oct 27.

8. Brown NJ, Mannix RC, O'Brien MJ, Gostine D, Collins MW, Meehan WP. Effect of Cognitive Activity Level on Duration of Post-Concussion Symptoms. Pediatrics 2014;133(2):1-6.

Posted April 22, 2013; most recently revised January 14, 2014; most recently reviewed December 4, 2015